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VaccineType of Vaccine1Date vaccine given (mo/day/yr)Funding Source (F,S,P)2Route3 and Site3VaccineVaccine Information Statement (VIS)Vaccinator5 (signature or initials and title)
Lot #Mfr.Date on VIS4Date 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
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132 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 207.206, "t": 307.195, "r": 254.126, "b": 293.875 }, "text": "_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7", "field_kind": "text", "label": "_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7", "pdf_field_name": "Meningococcal ACWY eg MenACWY MCV4 MPSV4 Give MenACWY IM7 Give MPSV4 Subcut7_11", "pdf_field_type": "Text", "reading_order": 133 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 254.821, "t": 293.484, "r": 290.606, "b": 280.041 }, "text": "• See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines", "field_kind": "text", "label": "• See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines", "pdf_field_name": "Text5", "pdf_field_type": "Text", "reading_order": 134 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 207.208, "t": 293.428, "r": 254.128, "b": 280.108 }, "text": "_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7", "field_kind": "text", "label": "_Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7", "pdf_field_name": "Meningococcal ACWY eg MenACWY MCV4 MPSV4 Give MenACWY IM7 Give MPSV4 Subcut7_11", "pdf_field_type": "Text", "reading_order": 135 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 292.92, "r": 206.04, "b": 279.48 }, "text": "Meningococcal B (e.g., MenB) Give MenB IM.7", "field_kind": "text", "label": "Meningococcal B (e.g., MenB) Give MenB IM.7", "pdf_field_name": "Meningococcal B eg MenB Give MenB IM7_2", "pdf_field_type": "Text", "reading_order": 136 }, { "page": 1, "type": "TEXT", "location": { "l": 33.12, "t": 270.96, "r": 317.52, "b": 248.4 }, "text": "See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).", "reading_order": 137 }, { "page": 1, "type": "FIGURE", "location": { "l": 34.32, "t": 270.72, "r": 43.68, "b": 260.16 }, "text": "", "reading_order": 138 }, { "page": 1, "type": "TITLE", "location": { "l": 33.6, "t": 238.56, "r": 172.32, "b": 226.56 }, "text": "How to Complete this Record", "reading_order": 139, "level": 4 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 33.6, "t": 224.16, "r": 310.32, "b": 203.04 }, "text": "Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).", "marker": "1.", "list_id": "L1", "level": 0, "reading_order": 140 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 202.8, "r": 297.6, "b": 181.92 }, "text": "Record the funding source of the vaccine given as either F (federal), S (state), or P (private).", "marker": "2.", "list_id": "L1", "level": 0, "reading_order": 141 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 33.84, "t": 181.68, "r": 319.68, "b": 139.44 }, "text": "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).", "marker": "3.", "list_id": "L1", "level": 0, "reading_order": 142 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 34.08, "t": 139.68, "r": 301.92, "b": 118.8 }, "text": "Record the publication date of each VIS as well as the date the VIS is given to the patient.", "marker": "4.", "list_id": "L1", "level": 0, "reading_order": 143 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 34.08, "t": 119.04, "r": 316.32, "b": 87.6 }, "text": "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.", "marker": "5.", "list_id": "L1", "level": 0, "reading_order": 144 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 34.08, "t": 87.12, "r": 317.76, "b": 76.56 }, "text": "For combination vaccines, fill in a row for each antigen in the combination.", "marker": "6.", "list_id": "L1", "level": 0, "reading_order": 145 }, { "page": 1, "type": "TABLE", "location": { "l": 339.84, "t": 239.04, "r": 576, "b": 110.64 }, "text": "
AbbreviationTrade Name and Manufacturer
TdapAdacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
TdDecavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
HepAHavrix (GSK); Vaqta (Merck)
HepBEngerix-B (GSK); Recombivax HB (Merck)
HepA-HepBTwinrix (GSK)
HPV2Cervarix (GSK)
HPV4, HPV5Gardasil, Gardasil 9 (Merck)
MMRMMRII (Merck)
VARVarivax (Merck)
MenACWYMenactra (Sanofi Pasteur); Menveo (GSK)
MPSV4Menomune (Sanofi Pasteur)
MenBBexsero (GSK); Trumenba (Pfizer)
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VaccineType of Vaccine1Date vaccine given (mo/day/yr)Funding Source (F,S,P)2Route3 and Site3VaccineVaccine Information Statement (VIS)Vaccinator5 (signature or initials and title)
Lot #Mfr.Date on VIS4Date 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
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"page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 608.52, "r": 320.16, "b": 594.96 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_2", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 608.52, "r": 574.92, "b": 594.96 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 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Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_3", "pdf_field_type": "Text", "reading_order": 21 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 594.24, "r": 289.68, "b": 580.68 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_3", "pdf_field_type": "Text", "reading_order": 22 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 594.24, "r": 320.16, "b": 580.68 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_3", "pdf_field_type": "Text", "reading_order": 23 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 594.24, "r": 574.92, "b": 580.68 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, 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"Text", "reading_order": 27 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 579.96, "r": 320.16, "b": 566.4 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_4", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 579.96, "r": 574.92, "b": 566.4 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give 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"pdf_field_type": "Text", "reading_order": 32 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 565.68, "r": 320.16, "b": 552.24 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_5", "pdf_field_type": "Text", "reading_order": 33 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 565.68, "r": 574.92, "b": 552.24 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or initials and title)_Influenza (e.g., IIV3, IIV4, ccIIV3, 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(mo/day/yr)_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_6", "pdf_field_type": "Text", "reading_order": 36 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 551.52, "r": 289.68, "b": 537.96 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_6", "pdf_field_type": "Text", "reading_order": 37 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 551.52, "r": 320.16, "b": 537.96 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_6", "pdf_field_type": "Text", "reading_order": 38 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 551.52, "r": 574.92, "b": 537.96 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or initials and title)_Influenza 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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", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_7", "pdf_field_type": "Text", "reading_order": 41 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 537.24, "r": 289.68, "b": 523.68 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_7", "pdf_field_type": "Text", "reading_order": 42 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 537.24, "r": 320.16, "b": 523.68 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_7", "pdf_field_type": "Text", "reading_order": 43 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 537.24, "r": 574.92, "b": 523.68 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or initials and 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"text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_8", "pdf_field_type": "Text", "reading_order": 46 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 522.96, "r": 289.68, "b": 509.4 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give 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}, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_9", "pdf_field_type": "Text", "reading_order": 51 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 508.68, "r": 289.68, "b": 495.24 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_9", "pdf_field_type": "Text", "reading_order": 52 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 508.68, "r": 320.16, "b": 495.24 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_9", "pdf_field_type": "Text", "reading_order": 53 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 508.68, "r": 574.92, "b": 495.24 }, "text": "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", "field_kind": "text", "label": "Vaccinator5 (signature or 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"b": 480.96 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_10", "pdf_field_type": "Text", "reading_order": 56 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 494.52, "r": 289.68, "b": 480.96 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_10", "pdf_field_type": "Text", "reading_order": 57 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 494.52, "r": 320.16, "b": 480.96 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_10", "pdf_field_type": "Text", "reading_order": 58 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 494.52, "r": 574.92, "b": 480.96 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Vaccinator5 signature or initials and titleInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_10", "pdf_field_type": "Text", "reading_order": 59 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 480.24, "r": 206.04, "b": 466.68 }, "text": "Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Type of Vaccine1Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_11", "pdf_field_type": "Text", "reading_order": 60 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 207.36, "t": 480.24, "r": 254.28, "b": 466.68 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_11", "pdf_field_type": "Text", "reading_order": 61 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 480.24, "r": 289.68, "b": 466.68 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source FSP2Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_11", "pdf_field_type": "Text", "reading_order": 62 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 291, "t": 480.24, "r": 320.16, "b": 466.68 }, "text": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Route3 and Site3_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Route3 and Site3Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_11", "pdf_field_type": "Text", "reading_order": 63 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.48, "t": 480.24, "r": 574.92, "b": 466.68 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Vaccinator5 signature or initials and titleInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_11", "pdf_field_type": "Text", "reading_order": 64 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 465.96, "r": 206.04, "b": 452.4 }, "text": "Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "field_kind": "text", "label": "Type of Vaccine1_Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.3 Give LAIV4 NAS.3", "pdf_field_name": "Type of Vaccine1Influenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_12", "pdf_field_type": "Text", "reading_order": 65 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 207.36, "t": 465.96, "r": 254.28, "b": 452.4 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Date vaccine given modayyrInfluenza eg IIV3 IIV4 ccIIV3 RIV3 LAIV4 Give IIV3 IIV4 ccIIV3 and RIV3 IM3 Give LAIV4 NAS3_12", "pdf_field_type": "Text", "reading_order": 66 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 255.6, "t": 465.96, "r": 289.68, "b": 452.4 }, "text": "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", "field_kind": "text", "label": "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", "pdf_field_name": "Funding Source 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"reading_order": 90 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 423.84, "t": 408.6, "r": 471.36, "b": 387.72 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined_6", "pdf_field_type": "Text", "reading_order": 91 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 472.92, "t": 408.6, "r": 518.16, "b": 387.72 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined_7", "pdf_field_type": "Text", "reading_order": 92 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 519.72, "t": 408.6, "r": 574.68, "b": 387.72 }, "text": "undefined", "field_kind": "text", "label": "undefined", "pdf_field_name": "undefined_8", "pdf_field_type": "Text", "reading_order": 93 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 386.52, "r": 206.04, "b": 373.44 }, "text": "Pneumococcal polysac", "field_kind": "text", "label": "Pneumococcal polysac", "pdf_field_name": "Pneumococcal polysac", "pdf_field_type": "Text", "reading_order": 94 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 372.72, "r": 206.04, "b": 359.16 }, "text": "charide (e.g., PPSV23", "field_kind": "text", "label": "charide (e.g., PPSV23", "pdf_field_name": "charide eg PPSV23", "pdf_field_type": "Text", "reading_order": 95 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 343.8, "r": 206.04, "b": 330.72 }, "text": "Zoster (HZV) Give Subcut.3", "field_kind": "text", "label": "Zoster (HZV) Give Subcut.3", "pdf_field_name": "Zoster HZV Give Subcut3", "pdf_field_type": "Text", "reading_order": 96 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 329.52, "r": 206.04, "b": 316.44 }, "text": "Hib Give IM.3", "field_kind": "text", "label": "Hib Give IM.3", "pdf_field_name": "Hib Give IM3", "pdf_field_type": "Text", "reading_order": 97 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 315.24, "r": 206.04, "b": 302.16 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other", "pdf_field_type": "Text", "reading_order": 98 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 301.44, "r": 206.04, "b": 287.88 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_2", "pdf_field_type": "Text", "reading_order": 99 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 287.16, "r": 206.04, "b": 273.72 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_3", "pdf_field_type": "Text", "reading_order": 100 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 132.96, "t": 273, "r": 206.04, "b": 259.68 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_4", "pdf_field_type": "Text", "reading_order": 101 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 33.84, "t": 250.32, "r": 312, "b": 228.72 }, "text": "See page 1 to record Tdap/Td, hepatitis A, 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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).", "marker": "3.", "list_id": "L3", "level": 0, "reading_order": 106 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 34.08, "t": 119.28, "r": 301.92, "b": 98.16 }, "text": "Record the publication date of each VIS as well as the date the VIS is given to the patient.", "marker": "4.", "list_id": "L3", "level": 0, "reading_order": 107 }, { "page": 2, "type": "LIST_ITEM", "location": { "l": 33.84, "t": 97.92, "r": 316.08, "b": 66.24 }, "text": "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.", "marker": "5.", "list_id": "L3", "level": 0, "reading_order": 108 }, { "page": 2, "type": "TABLE", 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AbbreviationTrade 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)
PCV13Prevnar 13 (Pfizer)
PPSV23Pneumovax 23 (Merck)
HZV (shingles)Zostavax (Merck)
HibActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck)
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Patient nameMahamud Omar
Birthdate5/31/1971 Chart number
PRACTICE NAME AND ADDRESS\nSmall Rural Clinic\n135 County Road D\nSmall Town, CD 46902
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VaccineType of Vaccine1Date vaccine given (mo/day/yr)Funding Source (F,S,P)2Route3 and Site3VaccineVaccine Information Statement (VIS)Vaccinator5 (signature or initials and title)
Lot #M/FDate on VIS4Date given4
Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3Td8/1/2002PIM/LAU0376AAA/P6/10/19948/1/2002JTA
Td9/1/2002PIM/LAU0376AAAVP6/10/19949/1/2002RVO
Td3/1/2003PIM/LAU0376AAAVP6/10/19943/1/2003TAA
Tdap3/1/2015PIM/LAAC52BC02AAGSK2/24/20153/1/2015JA
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.3MMR8/1/2002PSubcut/RA0025LMSD6/13/20028/1/2002JTA
MMR11/1/2002PSubcut/RA0025LMSD6/13/200211/1/2002TAA
Varicella (VAR) Give Subcut.3VAR8/1/2002PSubcut/LA0799MMSD12/16/19988/1/2002JTA
VAR11/1/2002PSubcut/LA0689MMSD12/16/199811/1/2002TAA
Meningococcal ACWY (e.g., MenACWY [MCV4], MPSV4) Give MenACWY IM.7 Give MPSV4 Subcut.7MenACWY7/12/2011PIM/RAM28011NOV1/2/20087/12/2011LTB
Menveo7/15/2016PIM/LAM12115NOV3/31/167/15/2016RVO
Meningococcal B (e.g., MenB) Give MenB IM.7MenB1/14/2016PIM/LAJ296203PFR8/14/20151/14/2016RVO
Trumenba3/15/2016PIM/LAJ296203PFR8/14/20153/15/2016RVO
Trumenba7/15/2016PIM/RAJ296203PFR8/14/20157/15/2016RVO
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"Text", "reading_order": 48 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 393.12, "t": 331.2, "r": 422.64, "b": 317.88 }, "text": "NOV_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ: < \u0003 > 0 9\u0017@\u000f 0369\u0017 \u0003*LYH\u00030HQ&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "field_kind": "text", "label": "NOV_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ$&:<\u0003>0&9\u0017@\u000f 0369\u0017\f\u0003*LYH\u00030HQ$&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "pdf_field_name": "fill_25", "pdf_field_type": "Text", "reading_order": 49 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 423.96, "t": 331.2, "r": 471.96, "b": 317.88 }, "text": "3/31/16_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ: < \u0003 > 0 9\u0017@\u000f 0369\u0017 \u0003*LYH\u00030HQ&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "field_kind": "text", "label": "3/31/16_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ$&:<\u0003>0&9\u0017@\u000f 0369\u0017\f\u0003*LYH\u00030HQ$&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "pdf_field_name": "fill_26", "pdf_field_type": "Text", "reading_order": 50 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 473.04, "t": 331.2, "r": 518.64, "b": 317.88 }, "text": "7/15/2016_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ: < \u0003 > 0 9\u0017@\u000f 0369\u0017 \u0003*LYH\u00030HQ&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "field_kind": "text", "label": "7/15/2016_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ$&:<\u0003>0&9\u0017@\u000f 0369\u0017\f\u0003*LYH\u00030HQ$&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "pdf_field_name": "fill_27", "pdf_field_type": "Text", "reading_order": 51 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 519.72, "t": 331.2, "r": 575.16, "b": 317.88 }, "text": "RVO_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ: < \u0003 > 0 9\u0017@\u000f 0369\u0017 \u0003*LYH\u00030HQ&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "field_kind": "text", "label": "RVO_Meningococcal ACWY H\u0011J\u0011\u000f\u00030HQ$&:<\u0003>0&9\u0017@\u000f 0369\u0017\f\u0003*LYH\u00030HQ$&:<\u0003 ,0\u00117\u0003*LYH\u00030369\u0017\u00036XEFXW\u00117", "pdf_field_name": "fill_28", "pdf_field_type": "Text", "reading_order": 52 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 556.44, "t": 302.64, "r": 575.16, "b": 289.08 }, "text": "RVO", "field_kind": "text", "label": "RVO", "pdf_field_name": "RVO", "pdf_field_type": "Text", "reading_order": 53 }, { "page": 3, "type": "FORM_FIELD", "location": { "l": 181.68, "t": 288.36, "r": 206.4, "b": 275.04 }, "text": "Trumenba", "field_kind": "text", "label": "Trumenba", "pdf_field_name": "Trumenba", "pdf_field_type": "Text", "reading_order": 54 }, { "page": 3, "type": "TEXT", "location": { "l": 33.12, "t": 266.16, "r": 318, "b": 244.08 }, "text": "See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).", "reading_order": 55 }, { "page": 3, "type": "TITLE", "location": { "l": 34.32, "t": 234.24, "r": 172.32, "b": 222.24 }, "text": "How to Complete this Record", "reading_order": 56, "level": 4 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 219.6, "r": 310.32, "b": 198.24 }, "text": "Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).", "marker": "1.", "list_id": "L4", "level": 0, "reading_order": 57 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 198.48, "r": 298.08, "b": 177.36 }, "text": "Record the funding source of the vaccine given as either F (federal), S (state), or P (private).", "marker": "2.", "list_id": "L4", "level": 0, "reading_order": 58 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 34.8, "t": 177.12, "r": 319.92, "b": 135.36 }, "text": "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).", "marker": "3.", "list_id": "L4", "level": 0, "reading_order": 59 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 135.36, "r": 302.4, "b": 114.48 }, "text": "Record the publication date of each VIS as well as the date the VIS is given to the patient.", "marker": "4.", "list_id": "L4", "level": 0, "reading_order": 60 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 114.48, "r": 316.56, "b": 83.04 }, "text": "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.", "marker": "5.", "list_id": "L4", "level": 0, "reading_order": 61 }, { "page": 3, "type": "LIST_ITEM", "location": { "l": 33.84, "t": 82.8, "r": 318.72, "b": 71.52 }, "text": "For combination vaccines, fill in a row for each antigen in the combination.", "marker": "6.", "list_id": "L4", "level": 0, "reading_order": 62 }, { "page": 3, "type": "TABLE", "location": { "l": 340.32, "t": 234.48, "r": 576.96, "b": 106.08 }, "text": "
AbbreviationTrade Name and Manufacturer
TdapAdacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
TdDecavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
HepAHavrix (GSK); Vaqta (Merck)
HepBEngerix-B (GSK); Recombivax HB (Merck)
HepA-HepBTwinrix (GSK)
HPV2Cervarix (GSK)
HPV4, HPV5Gardasil, Gardasil 9 (Merck)
MMRMMRII (Merck)
VARVarivax (Merck)
MenACWYMenactra (Sanofi Pasteur); Menveo (GSK)
MPSV4Menomune (Sanofi Pasteur)
MenBBexsero (GSK); Trumenba (Pfizer)
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Boostrix (GlaxoSmithKline [GSK])", "html_text": "Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 2, "location": [ 340.32, 204.8492, 576.96, 214.7262 ], "cells": [ { "location": [ 340.32, 204.8492, 458.64, 214.7262 ], "text": "Td", "html_text": "Td", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 204.8492, 576.96, 214.7262 ], "text": "Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)", "html_text": "Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 3, "location": [ 340.32, 194.9723, 576.96, 204.8492 ], "cells": [ { "location": [ 340.32, 194.9723, 458.64, 204.8492 ], "text": "HepA", "html_text": "HepA", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 194.9723, 576.96, 204.8492 ], "text": "Havrix (GSK); Vaqta (Merck)", "html_text": "Havrix (GSK); Vaqta (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 4, "location": [ 340.32, 185.0954, 576.96, 194.9723 ], "cells": [ { "location": [ 340.32, 185.0954, 458.64, 194.9723 ], "text": "HepB", "html_text": "HepB", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 185.0954, 576.96, 194.9723 ], "text": "Engerix-B (GSK); Recombivax HB (Merck)", "html_text": "Engerix-B (GSK); Recombivax HB (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 5, "location": [ 340.32, 175.2185, 576.96, 185.0954 ], "cells": [ { "location": [ 340.32, 175.2185, 458.64, 185.0954 ], "text": "HepA-HepB", "html_text": "HepA-HepB", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 175.2185, 576.96, 185.0954 ], "text": "Twinrix (GSK)", "html_text": "Twinrix (GSK)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 6, "location": [ 340.32, 165.3415, 576.96, 175.2185 ], "cells": [ { "location": [ 340.32, 165.3415, 458.64, 175.2185 ], "text": "HPV2", "html_text": "HPV2", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 165.3415, 576.96, 175.2185 ], "text": "Cervarix (GSK)", "html_text": "Cervarix (GSK)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 7, "location": [ 340.32, 155.4646, 576.96, 165.3415 ], "cells": [ { "location": [ 340.32, 155.4646, 458.64, 165.3415 ], "text": "HPV4, HPV5", "html_text": "HPV4, HPV5", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 155.4646, 576.96, 165.3415 ], "text": "Gardasil, Gardasil 9 (Merck)", "html_text": "Gardasil, Gardasil 9 (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 8, "location": [ 340.32, 145.5877, 576.96, 155.4646 ], "cells": [ { "location": [ 340.32, 145.5877, 458.64, 155.4646 ], "text": "MMR", "html_text": "MMR", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 145.5877, 576.96, 155.4646 ], "text": "MMRII (Merck)", "html_text": "MMRII (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 9, "location": [ 340.32, 135.7108, 576.96, 145.5877 ], "cells": [ { "location": [ 340.32, 135.7108, 458.64, 145.5877 ], "text": "VAR", "html_text": "VAR", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 135.7108, 576.96, 145.5877 ], "text": "Varivax (Merck)", "html_text": "Varivax (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 10, "location": [ 340.32, 125.8338, 576.96, 135.7108 ], "cells": [ { "location": [ 340.32, 125.8338, 458.64, 135.7108 ], "text": "MenACWY", "html_text": "MenACWY", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 125.8338, 576.96, 135.7108 ], "text": "Menactra (Sanofi Pasteur); Menveo (GSK)", "html_text": "Menactra (Sanofi Pasteur); Menveo (GSK)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 11, "location": [ 340.32, 115.9569, 576.96, 125.8338 ], "cells": [ { "location": [ 340.32, 115.9569, 458.64, 125.8338 ], "text": "MPSV4", "html_text": "MPSV4", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 115.9569, 576.96, 125.8338 ], "text": "Menomune (Sanofi Pasteur)", "html_text": "Menomune (Sanofi Pasteur)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 12, "location": [ 340.32, 106.08, 576.96, 115.9569 ], "cells": [ { "location": [ 340.32, 106.08, 458.64, 115.9569 ], "text": "MenB", "html_text": "MenB", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.64, 106.08, 576.96, 115.9569 ], "text": "Bexsero (GSK); Trumenba (Pfizer)", "html_text": "Bexsero (GSK); Trumenba (Pfizer)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" } ], "n_rows": 13, "n_cols": 2, "ref": "#/tables/2", "reading_order": 63 }, { "page": 3, "type": "TEXT", "location": { "l": 31.68, "t": 53.28, "r": 552, "b": 40.08 }, "text": "IMMUNIZATION ACTION COALITION Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org", "reading_order": 64 } ] }, { "page": 4, "items": [ { "page": 4, "type": "TEXT", "location": { "l": 34.08, "t": 756.48, "r": 215.04, "b": 725.04 }, "text": "Vaccine Administration Record for Adults (continued)", "reading_order": 0 }, { "page": 4, "type": "TEXT", "location": { "l": 33.84, "t": 711.84, "r": 318.24, "b": 668.64 }, "text": "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.", "reading_order": 1 }, { "page": 4, "type": "TEXT", "location": { "l": 339.36, "t": 759.84, "r": 521.52, "b": 727.44 }, "text": "Patient name Mahamud Omar\nBirthdate 5/31/1971 Chart number", "reading_order": 2 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 520.08, "t": 745.2, "r": 576.6, "b": 729.6 }, "text": "LUWKGDWH &KDUW QXPEHU", "field_kind": "text", "label": "LUWKGDWH &KDUW QXPEHU", "pdf_field_name": "LUWKGDWH KDUW QXPEHU_2", "pdf_field_type": "Text", "reading_order": 3 }, { "page": 4, "type": "TEXT", "location": { "l": 341.04, "t": 719.76, "r": 576.48, "b": 707.94 }, "text": "PRACTICE NAME AND ADDRESS", "reading_order": 4 }, { "page": 4, "type": "TEXT", "location": { "l": 341.04, "t": 707.94, "r": 576.48, "b": 696.12 }, "text": "Small Rural Clinic", "reading_order": 5 }, { "page": 4, "type": "TEXT", "location": { "l": 341.04, "t": 696.12, "r": 576.48, "b": 684.3 }, "text": "135 County Road D", "reading_order": 6 }, { "page": 4, "type": "TEXT", "location": { "l": 341.04, "t": 684.3, "r": 576.48, "b": 672.48 }, "text": "Small Town, CD 46902", "reading_order": 7 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 454.56, "t": 717.12, "r": 575.16, "b": 672 }, "text": "practice name and address Small Rural Clinic 135 County Road D Small Town, CD 46902", "field_kind": "text", "label": "practice name and address Small Rural Clinic 135 County Road D Small Town, CD 46902", "pdf_field_name": "practice name and address Small Rural Clinic 135 County Road D Small Town CD 46902_2", "pdf_field_type": "Text", "reading_order": 8 }, { "page": 4, "type": "TABLE", "location": { "l": 36.24, "t": 652.32, "r": 576.96, "b": 250.56 }, "text": "
VaccineType of Vaccine1Date vaccine given (mo/day/yr)Funding Source (F,S,P)2Route3 and Site3VaccineVaccine Information Statement (VIS)Vaccinator5 (signature or initials and title)
Lot #Mfr.Date on VIS4Date given4
Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4)\\nGive IIV3, IIV4, ccIIV3, and RIV3 IM.3\\nGive LAIV4 NAS.3Fluoval10/2/2009FIM/RA2F600411GSK8/11/0910/2/09PWS
H1N112/7/2009PIM/RA10092224PNOV10/2/0912/7/09DLW
Afluoria9/12/2010PIM/RA06949111ACSL8/10/109/12/10TAA
Fluaval10/1/2011PIM/LA2F600411GSK8/10/1110/1/11JTA
IV39/5/2012PIM/RAM50907CSL7/2/129/5/12KKC
RIV312/2/2013PIM/RA350603FPSC7/26/1312/2/13DCP
IV410/5/2014PIM/RAUI196AAPMC8/19/1410/5/14JTA
IV411/2/2015PIM/LA111773PNOV8/7/1511/2/15DCP
Pneumococcal conjugate (e.g., PCV13) Give PCV13 IM.3PCV1311/1/2012PIM/LA7-5096-06AWYE4/16/1011/1/12CJP
Pneumococcal polysaccharide (e.g., PPSV23)\\nGive PPSV23 IM or Subcut.3PPSV239/10/2011PIM/LA663012/1163XMSD10/6/099/10/11DLW
PPSV239/15/2015P/LA663860/1626XMSD4/24/159/15/15TAA
Zoster (HZV) Give Subcut.3
Hib Give IM.3AcHIB11/1/2011PIM/RAD05561PMC2/4/1411/1/14MAT
Other
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charide\u0003\u000bH\u0011J\u0011\u000f\u00033369\u0015\u0016\f\u0003 *LYH\u00033369\u0015\u0016\u0003,0\u0003RU\u0003 6XEFXW\u00113", "field_kind": "text", "label": "9/15/15_Pneumococcal polysac- charide\u0003\u000bH\u0011J\u0011\u000f\u00033369\u0015\u0016\f\u0003 *LYH\u00033369\u0015\u0016\u0003,0\u0003RU\u0003 6XEFXW\u00113", "pdf_field_name": "fill_72", "pdf_field_type": "Text", "reading_order": 93 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 519.84, "t": 348.96, "r": 575.4, "b": 335.4 }, "text": "TAA_Pneumococcal polysac- charide\u0003\u000bH\u0011J\u0011\u000f\u00033369\u0015\u0016\f\u0003 *LYH\u00033369\u0015\u0016\u0003,0\u0003RU\u0003 6XEFXW\u00113", "field_kind": "text", "label": "TAA_Pneumococcal polysac- charide\u0003\u000bH\u0011J\u0011\u000f\u00033369\u0015\u0016\f\u0003 *LYH\u00033369\u0015\u0016\u0003,0\u0003RU\u0003 6XEFXW\u00113", "pdf_field_name": "fill_73", "pdf_field_type": "Text", "reading_order": 94 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 86.88, "t": 320.04, "r": 132.12, "b": 306.96 }, "text": "Hib\u0003*LYH\u0003,0\u00113", "field_kind": "text", "label": "Hib\u0003*LYH\u0003,0\u00113", "pdf_field_name": "HibLYH03", "pdf_field_type": "Text", "reading_order": 95 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 133.44, "t": 305.76, "r": 206.52, "b": 292.68 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_5", "pdf_field_type": "Text", "reading_order": 96 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 133.44, "t": 291.96, "r": 206.52, "b": 278.4 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_6", "pdf_field_type": "Text", "reading_order": 97 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 133.44, "t": 277.68, "r": 206.52, "b": 264.12 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_7", "pdf_field_type": "Text", "reading_order": 98 }, { "page": 4, "type": "FORM_FIELD", "location": { "l": 133.44, "t": 263.4, "r": 206.52, "b": 250.08 }, "text": "Other", "field_kind": "text", "label": "Other", "pdf_field_name": "Other_8", "pdf_field_type": "Text", "reading_order": 99 }, { "page": 4, "type": "TEXT", "location": { "l": 33.36, "t": 241.44, "r": 311.52, "b": 220.08 }, "text": "See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB vaccines.", "reading_order": 100 }, { "page": 4, "type": "FIGURE", "location": { "l": 34.32, "t": 240.96, "r": 43.92, "b": 230.4 }, "text": "", "reading_order": 101 }, { "page": 4, "type": "TITLE", "location": { "l": 34.56, "t": 208.8, "r": 172.32, "b": 196.8 }, "text": "How to Complete this Record", "reading_order": 102, "level": 4 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 34.56, "t": 194.4, "r": 310.56, "b": 173.04 }, "text": "Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right).", "marker": "1.", "list_id": "L5", "level": 0, "reading_order": 103 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 173.04, "r": 298.32, "b": 151.92 }, "text": "Record the funding source of the vaccine given as either F (federal), S (state), or P (private).", "marker": "2.", "list_id": "L5", "level": 0, "reading_order": 104 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 34.32, "t": 151.92, "r": 320.4, "b": 109.68 }, "text": "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).", "marker": "3.", "list_id": "L5", "level": 0, "reading_order": 105 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 34.56, "t": 109.92, "r": 302.64, "b": 89.04 }, "text": "Record the publication date of each VIS as well as the date the VIS is given to the patient.", "marker": "4.", "list_id": "L5", "level": 0, "reading_order": 106 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 34.56, "t": 89.04, "r": 316.32, "b": 56.88 }, "text": "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.", "marker": "5.", "list_id": "L5", "level": 0, "reading_order": 107 }, { "page": 4, "type": "TABLE", "location": { "l": 341.28, "t": 222.24, "r": 576.24, "b": 60.48 }, "text": "
AbbreviationTrade 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)
PCV13Prevnar 13 (Pfizer)
PPSV23Pneumovax 23 (Merck)
HZV (shingles)Zostavax (Merck)
HibActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck)
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IIV4 (inactivated influenza vaccine, quadrivalent); ccIIV3 (cell culture-based inactivated influenza vaccine, trivalent); RIV3 (inactivated recombinant influenza vaccine, trivalent)", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.76, 176.0229, 576.24, 199.1314 ], "text": "Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, Fluid, Fluclevax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone, Fluzone Intradermal, Fluzone High-Dose (Sanofi Pasteur)", "html_text": "Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, Fluid, Fluclevax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone, Fluzone Intradermal, Fluzone High-Dose (Sanofi Pasteur)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 2, "location": [ 341.28, 152.9143, 576.24, 176.0229 ], "cells": [ { "location": [ 341.28, 152.9143, 458.76, 176.0229 ], "text": "LAIV (live attenuated influenza vaccine, quadrivalent)", "html_text": "LAIV (live attenuated influenza vaccine, quadrivalent)", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.76, 152.9143, 576.24, 176.0229 ], "text": "FluMist (MedImmune)", "html_text": "FluMist (MedImmune)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 3, "location": [ 341.28, 129.8057, 576.24, 152.9143 ], "cells": [ { "location": [ 341.28, 129.8057, 458.76, 152.9143 ], "text": "PCV13", "html_text": "PCV13", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.76, 129.8057, 576.24, 152.9143 ], "text": "Prevnar 13 (Pfizer)", "html_text": "Prevnar 13 (Pfizer)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 4, "location": [ 341.28, 106.6971, 576.24, 129.8057 ], "cells": [ { "location": [ 341.28, 106.6971, 458.76, 129.8057 ], "text": "PPSV23", "html_text": "PPSV23", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.76, 106.6971, 576.24, 129.8057 ], "text": "Pneumovax 23 (Merck)", "html_text": "Pneumovax 23 (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 5, "location": [ 341.28, 83.5886, 576.24, 106.6971 ], "cells": [ { "location": [ 341.28, 83.5886, 458.76, 106.6971 ], "text": "HZV (shingles)", "html_text": "HZV (shingles)", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.76, 83.5886, 576.24, 106.6971 ], "text": "Zostavax (Merck)", "html_text": "Zostavax (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" }, { "row_index": 6, "location": [ 341.28, 60.48, 576.24, 83.5886 ], "cells": [ { "location": [ 341.28, 60.48, 458.76, 83.5886 ], "text": "Hib", "html_text": "Hib", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" }, { "location": [ 458.76, 60.48, 576.24, 83.5886 ], "text": "ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck)", "html_text": "ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib (Merck)", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/2" } ], "ref": "#/tables/2" } ], "n_rows": 7, "n_cols": 2, "ref": "#/tables/2", "reading_order": 108 } ] } ]