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Vaccine Administration Record for Adults
Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.
PAGE 1 OF 2
Patient name
Patient name
Birthdate
Chart number
Birthdate Chart number
PRACTICE NAME AND ADDRESS
practice name and address
| Vaccine | Type of Vaccine1 | Date vaccine given (mo/day/yr) | Funding Source (F,S,P)2 | Route3 and Site3 | Vaccine | Vaccine Information Statement (VIS) | Vaccinator5 (signature or initials and title) | ||
|---|---|---|---|---|---|---|---|---|---|
| Lot # | Mfr. | Date on VIS4 | Date given4 | ||||||
| Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3 | |||||||||
| Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3 | |||||||||
| Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3 | |||||||||
| Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3 | |||||||||
| Measles, Mumps, Rubella (MMR) Give Subcut.3 | |||||||||
| Varicella (VAR) Give Subcut.3 | |||||||||
| Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7 | |||||||||
| Meningococcal B (e.g., MenB) Give MenB IM.7 | |||||||||
(mo/day/yr)
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Diphtheria, Pertussis
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Diphtheria, Pertussis
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Type of Vaccine1_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date on VIS4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date given4_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Vaccinator5 (signature or initials and title)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepA, HepA-HepB)
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepA, HepA-HepB)
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
(e.g., HepA, HepA-HepB)
Mfr._Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Route3 and Site3_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Lot #_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepB, HepA-HepB)
Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
(e.g., HepB, HepA-HepB)
Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
Human papillomavirus
Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3
(HPV2, HPV4, HPV9)
Varicella (VAR) Give Subcut.3
Date vaccine given (mo/day/yr)_Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Measles, Mumps, Rubella
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
(MMR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Measles, Mumps, Rubella (MMR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
(MMR) Give Subcut.3
Measles, Mumps, Rubella (MMR) Give Subcut.3
Varicella (VAR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
(VAR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
Meningococcal ACWY
Varicella (VAR) Give Subcut.3
_Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
(e.g., MenACWY [MCV4],
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
(e.g., MenB) Give MenB
Meningococcal B (e.g., MenB) Give MenB IM.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
Meningococcal B
Meningococcal B (e.g., MenB) Give MenB IM.7
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
• See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines
_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7
Meningococcal B (e.g., MenB) Give MenB IM.7
See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).
How to Complete this Record
Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).
Record the funding source of the vaccine given as either F (federal), S (state), or P (private).
Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral (PO) and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).
Record the publication date of each VIS as well as the date the VIS is given to the patient.
To meet the space constraints of this form and federal requirements for documentation, a healthcare setting may want to keep a reference list of vaccinators that includes their initials and titles.
For combination vaccines, fill in a row for each antigen in the combination.
| Abbreviation | Trade Name and Manufacturer |
|---|---|
| Tdap | Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK]) |
| Td | Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs) |
| HepA | Havrix (GSK); Vaqta (Merck) |
| HepB | Engerix-B (GSK); Recombivax HB (Merck) |
| HepA-HepB | Twinrix (GSK) |
| HPV2 | Cervarix (GSK) |
| HPV4, HPV5 | Gardasil, Gardasil 9 (Merck) |
| MMR | MMRII (Merck) |
| VAR | Varivax (Merck) |
| MenACWY | Menactra (Sanofi Pasteur); Menveo (GSK) |
| MPSV4 | Menomune (Sanofi Pasteur) |
| MenB | Bexsero (GSK); Trumenba (Pfizer) |
Trade Name and Manufacturer
Tdap
Td
HepA
Havrix (GSK); Vaqta (Merck)
HepB
Engerix-B (GSK); Recombivax HB (Merck)
Twinrix (GSK)
HPV2
Cervarix (GSK)
Gardasil, Gardasil 9 (Merck)
MMR
MMRII (Merck)
VAR
Varivax (Merck)
Menactra (Sanofi Pasteur); Menveo (GSK)
MPSV4
Menomune (Sanofi Pasteur)
MenB
Bexsero (GSK); Trumenba (Pfizer)
IMMUNIZATION ACTION COALITION
Page 2
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Vaccine Administration Record for Adults (continued)
Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.
Patient name___
PAGE 2 OF 2
Patient name
Patient name
Birthdate ___ Chart number ___
Birthdate
Chart number
PRACTICE NAME AND ADDRESS
practice name and address
| Vaccine | Type of Vaccine1 | Date vaccine given (mo/day/yr) | Funding Source (F,S,P)2 | Route3 and Site3 | Vaccine | Vaccine Information Statement (VIS) | Vaccinator5 (signature or initials and title) | ||
|---|---|---|---|---|---|---|---|---|---|
| Lot # | Mfr. | Date on VIS4 | Date given4 | ||||||
| Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) | |||||||||
| Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 | |||||||||
| Give LAIV4 NAS.3 | |||||||||
| Pneumococcal conjugate (e.g., PCV13) Give PCV13 IM.3 | |||||||||
| Pneumococcal polysaccharide (e.g., PPSV23) Give PPSV23 IM or Subcut.3 | |||||||||
| Zoster (HZV) Give Subcut.3 | |||||||||
| Hib Give IM.3 | |||||||||
| Other | |||||||||
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Date vaccine given (mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Funding Source (F,S,P)2_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3
e.g., PCV13) Give PCV13 IM.3
undefined
undefined
undefined
undefined
undefined
undefined
undefined
undefined
Pneumococcal polysac
charide (e.g., PPSV23
Zoster (HZV) Give Subcut.3
Hib Give IM.3
Other
Other
Other
Other
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB vaccines.
How to Complete this Record
Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).
Record the funding source of the vaccine given as either F (federal), S (state), or P (private).
Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral (PO) and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).
Record the publication date of each VIS as well as the date the VIS is given to the patient.
To meet the space constraints of this form and federal requirements for documentation, a healthcare setting may want to keep a reference list of vaccinators that includes their initials and titles.
| Abbreviation | Trade Name and Manufacturer |
|---|---|
| IIV3 (inactivated influenza vaccine, trivalent); IIV4 (inactivated influenza vaccine, quadrivalent); ccIIV3 (cell culture-based inactivated influenza vaccine, trivalent); RIV3 (inactivated recombinant influenza vaccine, trivalent) | Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, Fluad, Flucelvax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone, Fluzone Intradermal, Fluzone High-Dose (Sanofi Pasteur) |
| LAIV (live attenuated influenza vaccine, quadrivalent) | FluMist (MedImmune) |
| PCV13 | Prevnar 13 (Pfizer) |
| PPSV23 | Pneumovax 23 (Merck) |
| HZV (shingles) | Zostavax (Merck) |
| Hib | ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck) |
Abbreviation
Trade Name and Manufacturer
(inactivated recombinant
FluMist (MedImmune)
rivalent]
PCV13
Prevnar 13 (Pfizer)
PPSV23
Pneumovax 23 (Merck)
HZV (shingles)
Zostavax (Merck)
Hib
(Merck)
www.immunize.org/catg.d/p2023.pdf Item #P2023-page 2 (4/16)
Page 3
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Vaccine Administration Record for Adults
Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.
PAGE 1 OF 2
| Patient name | Mahamud Omar |
|---|---|
| Birthdate | 5/31/1971 Chart number |
| PRACTICE NAME AND ADDRESS Small Rural Clinic 135 County Road D Small Town, CD 46902 | |
LUWKGDWH &KDUW QXPEHU
practice name and address Small Rural Clinic 135 County Road D Small Town, CD 46902
| Vaccine | Type of Vaccine1 | Date vaccine given (mo/day/yr) | Funding Source (F,S,P)2 | Route3 and Site3 | Vaccine | Vaccine Information Statement (VIS) | Vaccinator5 (signature or initials and title) | ||
|---|---|---|---|---|---|---|---|---|---|
| Lot # | M/F | Date on VIS4 | Date given4 | ||||||
| Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3 | Td | 8/1/2002 | P | IM/LA | U0376AA | A/P | 6/10/1994 | 8/1/2002 | JTA |
| Td | 9/1/2002 | P | IM/LA | U0376AA | AVP | 6/10/1994 | 9/1/2002 | RVO | |
| Td | 3/1/2003 | P | IM/LA | U0376AA | AVP | 6/10/1994 | 3/1/2003 | TAA | |
| Tdap | 3/1/2015 | P | IM/LA | AC52BC02AA | GSK | 2/24/2015 | 3/1/2015 | JA | |
| Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3 | |||||||||
| Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3 | |||||||||
| Human papillomavirus (HPV2, HPV4, HPV9) Give IM.3 | |||||||||
| Measles, Mumps, Rubella (MMR) Give Subcut.3 | MMR | 8/1/2002 | P | Subcut/RA | 0025L | MSD | 6/13/2002 | 8/1/2002 | JTA |
| MMR | 11/1/2002 | P | Subcut/RA | 0025L | MSD | 6/13/2002 | 11/1/2002 | TAA | |
| Varicella (VAR) Give Subcut.3 | VAR | 8/1/2002 | P | Subcut/LA | 0799M | MSD | 12/16/1998 | 8/1/2002 | JTA |
| VAR | 11/1/2002 | P | Subcut/LA | 0689M | MSD | 12/16/1998 | 11/1/2002 | TAA | |
| Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7 | MenACWY | 7/12/2011 | P | IM/RA | M28011 | NOV | 1/2/2008 | 7/12/2011 | LTB |
| Menveo | 7/15/2016 | P | IM/LA | M12115 | NOV | 3/31/16 | 7/15/2016 | RVO | |
| Meningococcal B (e.g., MenB) Give MenB IM.7 | MenB | 1/14/2016 | P | IM/LA | J296203 | PFR | 8/14/2015 | 1/14/2016 | RVO |
| Trumenba | 3/15/2016 | P | IM/LA | J296203 | PFR | 8/14/2015 | 3/15/2016 | RVO | |
| Trumenba | 7/15/2016 | P | IM/RA | J296203 | PFR | 8/14/2015 | 7/15/2016 | RVO | |
'DWHRQ9,6
/RW
0IU
'DWHJLYHQ
Td
Td
Td
Tdap_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
3/1/2015_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
P_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
IM/LA_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
AC52B030AA_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
GSK_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
2/24/2015_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
3/1/2015_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
JA_Tetanus, Diphtheria, Pertussis HJ7GDS7G *LYH,03
Hepatitis A6 HJ+HS$+HS$+HS% *LYH,03
Hepatitis A6 HJ+HS$+HS$+HS% *LYH,03
Hepatitis A6 HJ+HS$+HS$+HS% *LYH,03
Hepatitis B6 HJ+HS%+HS$+HS% *LYH,03
Hepatitis B6 HJ+HS%+HS$+HS% *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
_Human papillomavirus +39+39+39 *LYH,03
MMR
MMR
VAR
P
7/12/2011
IM/RA
1/2/2008
7/12/2011
Menveo_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
7/15/2016_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
P_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
IM/LA_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
M12115_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
NOV_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
3/31/16_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
7/15/2016_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
RVO_Meningococcal ACWY HJ0HQ$&:<>0&9@ 0369 *LYH0HQ$&:< ,07*LYH03696XEFXW7
RVO
Trumenba
See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).
How to Complete this Record
Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).
Record the funding source of the vaccine given as either F (federal), S (state), or P (private).
Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral (PO) and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).
Record the publication date of each VIS as well as the date the VIS is given to the patient.
To meet the space constraints of this form and federal requirements for documentation, a healthcare setting may want to keep a reference list of vaccinators that includes their initials and titles.
For combination vaccines, fill in a row for each antigen in the combination.
| Abbreviation | Trade Name and Manufacturer |
|---|---|
| Tdap | Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK]) |
| Td | Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs) |
| HepA | Havrix (GSK); Vaqta (Merck) |
| HepB | Engerix-B (GSK); Recombivax HB (Merck) |
| HepA-HepB | Twinrix (GSK) |
| HPV2 | Cervarix (GSK) |
| HPV4, HPV5 | Gardasil, Gardasil 9 (Merck) |
| MMR | MMRII (Merck) |
| VAR | Varivax (Merck) |
| MenACWY | Menactra (Sanofi Pasteur); Menveo (GSK) |
| MPSV4 | Menomune (Sanofi Pasteur) |
| MenB | Bexsero (GSK); Trumenba (Pfizer) |
IMMUNIZATION ACTION COALITION Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org
Page 4
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Vaccine Administration Record for Adults (continued)
Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.
Patient name Mahamud Omar
Birthdate 5/31/1971 Chart number
LUWKGDWH &KDUW QXPEHU
PAGE 2 OF 2
PRACTICE NAME AND ADDRESS
Small Rural Clinic
135 County Road D
Small Town, CD 46902
practice name and address Small Rural Clinic 135 County Road D Small Town, CD 46902
| Vaccine | Type of Vaccine1 | Date vaccine given (mo/day/yr) | Funding Source (F,S,P)2 | Route3 and Site3 | Vaccine | Vaccine Information Statement (VIS) | Vaccinator5 (signature or initials and title) | ||
|---|---|---|---|---|---|---|---|---|---|
| Lot # | Mfr. | Date on VIS4 | Date given4 | ||||||
| Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4)\nGive IIV3, IIV4, ccIIV3, and RIV3 IM.3\nGive LAIV4 NAS.3 | Fluoval | 10/2/2009 | F | IM/RA | 2F600411 | GSK | 8/11/09 | 10/2/09 | PWS |
| H1N1 | 12/7/2009 | P | IM/RA | 10092224P | NOV | 10/2/09 | 12/7/09 | DLW | |
| Afluoria | 9/12/2010 | P | IM/RA | 06949111A | CSL | 8/10/10 | 9/12/10 | TAA | |
| Fluaval | 10/1/2011 | P | IM/LA | 2F600411 | GSK | 8/10/11 | 10/1/11 | JTA | |
| IV3 | 9/5/2012 | P | IM/RA | M50907 | CSL | 7/2/12 | 9/5/12 | KKC | |
| RIV3 | 12/2/2013 | P | IM/RA | 350603F | PSC | 7/26/13 | 12/2/13 | DCP | |
| IV4 | 10/5/2014 | P | IM/RA | UI196AA | PMC | 8/19/14 | 10/5/14 | JTA | |
| IV4 | 11/2/2015 | P | IM/LA | 111773P | NOV | 8/7/15 | 11/2/15 | DCP | |
| Pneumococcal conjugate (e.g., PCV13) Give PCV13 IM.3 | PCV13 | 11/1/2012 | P | IM/LA | 7-5096-06A | WYE | 4/16/10 | 11/1/12 | CJP |
| Pneumococcal polysaccharide (e.g., PPSV23)\nGive PPSV23 IM or Subcut.3 | PPSV23 | 9/10/2011 | P | IM/LA | 663012/1163X | MSD | 10/6/09 | 9/10/11 | DLW |
| PPSV23 | 9/15/2015 | P | /LA | 663860/1626X | MSD | 4/24/15 | 9/15/15 | TAA | |
| Zoster (HZV) Give Subcut.3 | |||||||||
| Hib Give IM.3 | AcHIB | 11/1/2011 | P | IM/RA | D05561 | PMC | 2/4/14 | 11/1/14 | MAT |
| Other | |||||||||
'DWHRQ9,6
Flulaval
H1N1
Afluria
Flulaval
IIV3
RIV3
PSC
12/2/13
IIV4
PMC
10/5/14
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IIV4_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/2015_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
IM/LA_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
111773P_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
NOV_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
8/7/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
11/2/15_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
DCP_,QƬXHQ]D HJ,,9,,9FF,,9 5,9/$,9 *LYH,,9,,9FF,,9 DQG5,9,03 *LYH/$,91$63
PPSV23
PPSV23_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
9/15/2015_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
P_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
IM/LA_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
663860/1626X_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
MSD_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
4/24/15_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
9/15/15_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
TAA_Pneumococcal polysac- charide HJ3369 *LYH3369,0RU 6XEFXW3
Hib*LYH,03
Other
Other
Other
Other
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB vaccines.
How to Complete this Record
Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).
Record the funding source of the vaccine given as either F (federal), S (state), or P (private).
Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral (PO) and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).
Record the publication date of each VIS as well as the date the VIS is given to the patient.
To meet the space constraints of this form and federal requirements for documentation, a healthcare setting may want to keep a reference list of vaccinators that includes their initials and titles.
| Abbreviation | Trade Name and Manufacturer |
|---|---|
| IIV3 (inactivated influenza vaccine, trivalent); IIV4 (inactivated influenza vaccine, quadrivalent); ccIIV3 (cell culture-based inactivated influenza vaccine, trivalent); RIV3 (inactivated recombinant influenza vaccine, trivalent) | Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, Fluid, Fluclevax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone, Fluzone Intradermal, Fluzone High-Dose (Sanofi Pasteur) |
| LAIV (live attenuated influenza vaccine, quadrivalent) | FluMist (MedImmune) |
| PCV13 | Prevnar 13 (Pfizer) |
| PPSV23 | Pneumovax 23 (Merck) |
| HZV (shingles) | Zostavax (Merck) |
| Hib | ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck) |