===== PAGE 1 =====

Patient name
Birthdate	Chart number
PRACTICE NAME AND ADDRESS

## 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.

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)
Vaccine	Type of Vaccine1	Date vaccine given (mo/day/yr)	Funding Source (F,S,P)2	Route3 and Site3	Lot #	Mfr.	Date on VIS4	Date given4	Vaccinator5 (signature or initials and title)
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
Measles, Mumps, Rubella (MMR) Give Subcut.3
Varicella (VAR) 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
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 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right). 2. Record the funding source of the vaccine given as either F (federal), S (state), or P (private). 3. 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). 4. Record the publication date of each VIS as well as the date the VIS is given to the patient. 5. 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. 6. 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)

===== PAGE 2 ===== ## 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___ Birthdate ___ Chart number ___ 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)
Vaccine	Type of Vaccine1	Date vaccine given (mo/day/yr)	Funding Source (F,S,P)2	Route3 and Site3	Lot #	Mfr.	Date on VIS4	Date given4	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











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

See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB vaccines. ## How to Complete this Record 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right). 2. Record the funding source of the vaccine given as either F (federal), S (state), or P (private). 3. 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). 4. Record the publication date of each VIS as well as the date the VIS is given to the patient. 5. 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)

===== PAGE 3 ===== IMMUNIZATION ACTION COALITION Saint Paul, Minnesota · 651-647-9009 · www.immunize.org · www.vaccineinformation.org ## 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.

Patient name	Mahamud Omar
Birthdate	5/31/1971 Chart number
PRACTICE NAME AND ADDRESS\nSmall Rural Clinic\n135 County Road D\nSmall 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)
Vaccine	Type of Vaccine1	Date vaccine given (mo/day/yr)	Funding Source (F,S,P)2	Route3 and Site3	Lot #	M/F	Date on VIS4	Date given4	Vaccinator5 (signature or initials and title)
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
Measles, Mumps, Rubella (MMR) Give Subcut.3	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
Varicella (VAR) Give Subcut.3	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

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)

===== PAGE 4 ===== Patient name Mahamud Omar Birthdate 5/31/1971 Chart number

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.

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)
Vaccine	Type of Vaccine1	Date vaccine given (mo/day/yr)	Funding Source (F,S,P)2	Route3 and Site3	Lot #	Mfr.	Date on VIS4	Date given4	Vaccinator5 (signature or initials and title)
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

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)