"Vaccine Administration Record for Adults Template - Immunization Action Coalition"

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Vaccine Administration Record
Patient name
for Adults
Birthdate
Chart number
practice name and address
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 Information
Date vaccine
Funding
Route
3
Vaccine
Vaccinator
5
Type of
Statement (VIS)
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
2
Site
3
initials and title)
Lot #
Mfr.
Date on VIS
4
Date given
4
Tetanus,
Diphtheria, Pertussis
(e.g., Tdap, Td)
Give IM.
3
Hepatitis A
6
(e.g., HepA, HepA-HepB)
Give IM.
3
Hepatitis B
6
(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
See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines
(e.g., travel vaccines).
How to Complete this Record
Abbreviation
Trade Name and Manufacturer
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
Tdap
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
vaccine (see table at right).
HepA
Havrix (GSK); Vaqta (Merck)
2. Record the funding source of the vaccine given as either F (federal),
HepB
Engerix-B (GSK); Recombivax HB (Merck)
S (state), or P (private).
HepA-HepB
Twinrix (GSK)
3. Record the route by which the vaccine was given as either intramuscular
HPV2
Cervarix (GSK)
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral
HPV4, HPV5
Gardasil, Gardasil 9 (Merck)
(PO) and also the site where it was administered as either RA (right arm),
MMR
MMRII (Merck)
LA (left arm), RT (right thigh), or LT (left thigh).
VAR
Varivax (Merck)
4. Record the publication date of each VIS as well as the date the VIS is
MenACWY
Menactra (Sanofi Pasteur); Menveo (GSK)
given to the patient.
MPSV4
Menomune (Sanofi Pasteur)
5. To meet the space constraints of this form and federal requirements for
MenB
Bexsero (GSK); Trumenba (Pfizer)
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.
Technical content reviewed by the Centers for Disease Control and Prevention
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf
Item #P2023 (4/16)
page 1 0f 2
Vaccine Administration Record
Patient name
for Adults
Birthdate
Chart number
practice name and address
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 Information
Date vaccine
Funding
Route
3
Vaccine
Vaccinator
5
Type of
Statement (VIS)
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
2
Site
3
initials and title)
Lot #
Mfr.
Date on VIS
4
Date given
4
Tetanus,
Diphtheria, Pertussis
(e.g., Tdap, Td)
Give IM.
3
Hepatitis A
6
(e.g., HepA, HepA-HepB)
Give IM.
3
Hepatitis B
6
(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
See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines
(e.g., travel vaccines).
How to Complete this Record
Abbreviation
Trade Name and Manufacturer
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
Tdap
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
vaccine (see table at right).
HepA
Havrix (GSK); Vaqta (Merck)
2. Record the funding source of the vaccine given as either F (federal),
HepB
Engerix-B (GSK); Recombivax HB (Merck)
S (state), or P (private).
HepA-HepB
Twinrix (GSK)
3. Record the route by which the vaccine was given as either intramuscular
HPV2
Cervarix (GSK)
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral
HPV4, HPV5
Gardasil, Gardasil 9 (Merck)
(PO) and also the site where it was administered as either RA (right arm),
MMR
MMRII (Merck)
LA (left arm), RT (right thigh), or LT (left thigh).
VAR
Varivax (Merck)
4. Record the publication date of each VIS as well as the date the VIS is
MenACWY
Menactra (Sanofi Pasteur); Menveo (GSK)
given to the patient.
MPSV4
Menomune (Sanofi Pasteur)
5. To meet the space constraints of this form and federal requirements for
MenB
Bexsero (GSK); Trumenba (Pfizer)
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.
Technical content reviewed by the Centers for Disease Control and Prevention
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf
Item #P2023 (4/16)
page 2 0f 2
Vaccine Administration Record
Patient name
for Adults
Birthdate
Chart number
(continued)
practice name and address
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 Information
Date vaccine
Funding
Route
3
Vaccine
Vaccinator
5
Type of
Statement (VIS)
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
Site
2
3
initials and title)
Date on VIS
4
Lot #
Mfr.
Date given
4
Influenza
(e.g., IIV3, IIV4, ccIIV3,
RIV3, LAIV4)
Give IIV3, IIV4, ccIIV3,
and RIV3 IM.
3
Give LAIV4 NAS.
3
Pneumococcal conjugate
3
(e.g., PCV13) Give PCV13 IM.
Pneumococcal polysac-
charide (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.
Abbreviation
Trade Name and Manufacturer
How to Complete this Record
IIV3 (inactivated influenza
vaccine, trivalent); IIV4
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
(inactivated influenza
Fluarix (GSK); Flublok (Protein Sciences Corp.);
vaccine, quadrivalent);
vaccine (see table at right).
Afluria, Fluad, Flucelvax, Fluvirin (Seqirus); FluLaval
ccIIV3 (cell culture-based
(GSK); Fluzone, Fluzone Intradermal, Fluzone
2. Record the funding source of the vaccine given as either F (federal),
inactivated influenza
High-Dose (Sanofi Pasteur)
S (state), or P (private).
vaccine, trivalent); RIV3
(inactivated recombinant
3. Record the route by which the vaccine was given as either intramuscular
influenza vaccine, trivalent)
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral
LAIV (live attenuated
(PO) and also the site where it was administered as either RA (right arm),
influenza vaccine, quad-
FluMist (MedImmune)
LA (left arm), RT (right thigh), or LT (left thigh).
rivalent]
4. Record the publication date of each VIS as well as the date the VIS is
PCV13
Prevnar 13 (Pfizer)
given to the patient.
PPSV23
Pneumovax 23 (Merck)
5. To meet the space constraints of this form and federal requirements for
HZV (shingles)
Zostavax (Merck)
documentation, a healthcare setting may want to keep a reference list of
ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib
Hib
(Merck)
vaccinators that includes their initials and titles.
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf
Item #P2023 – page 2 (4/16)
page 1 0f 2
Mahamud Omar
Vaccine Administration Record
5/31/1971
for Adults
practice name and address
Small Rural Clinic
135 County Road D
Small Town, CD 46902
Vaccine Information
Date vaccine
Funding
Route
3
Vaccine
Vaccinator
5
Type of
Statement (VIS)
Vaccine
given
Source
and
Vaccine
1
Site
3
P
Td
IM/LA
UO376AA
AVP
JTA
8/1/2002
6/10/1994 8/1/2002
Tetanus,
Diphtheria, Pertussis
Td
P
IM/LA
UO376AA
AVP
RVO
9/1/2002
6/10/1994 9/1/2002
Td
P
IM/LA
UO376AA
AVP
TAA
3/1/2003
6/10/1994 3/1/2003
3
P
Tdap
IM/LA AC52B030AA
GSK
JA
3/1/2015
2/24/2015 3/1/2015
Hepatitis A
6
3
Hepatitis B
6
3
Human papillomavirus
3
MMR
0025L
MSD
JTA
P
8/1/2002
6/13/2002 8/1/2002
Subcut/RA
Measles, Mumps, Rubella
3
MMR
0025L
MSD
TAA
P
11/1/2002
Subcut/RA
6/13/2002 11/1/2002
VAR
0799M
MSD
JTA
8/1/2002
P
12/16/1998 8/1/2002
Varicella
Subcut/LA
3
VAR
0689M
MSD
12/16/1998 11/1/2002
TAA
11/1/2002
P
Subcut/LA
MenACWY
P
M28011
NOV
LTB
7/12/2011
IM/RA
1/2/2008
7/12/2011
Meningococcal ACWY
Menveo
P
M12115
NOV
RVO
7/15/2016
IM/LA
3/31/16
7/15/2016
7
7
J296203
PFR
RVO
MenB
1/14/2016
P
IM/LA
8/14/2015 1/14/2016
Meningococcal B
Trumenba
J296203
PFR
RVO
3/15/2016
P
IM/LA
8/14/2015 3/15/2016
7
Trumenba
J296203
PFR
RVO
7/15/2016
P
IM/RA
8/14/2015
7/15/2016
See page 2
How to Complete this Record
Abbreviation
Trade Name and Manufacturer
Tdap
Td
HepA
T
Immunization Action Coalition
Saint Paul, Minnesota 651 - 647 - 9009 www.immunize.org www.vaccineinformation.org
p
page 2 0f 2
Mahamud Omar
Vaccine Administration Record
5/31/1971
for Adults
practice name and address
Small Rural Clinic
135 County Road D
Small Town, CD 46902
Vaccine Information
Date vaccine
Funding
Route
3
Vaccinator
Vaccine
5
Type of
Statement (VIS)
Vaccine
given
Source
and
Vaccine
1
Site
3
Flulaval
F
GSK
PWS
10/2/2009
IM/RA
2F600411
8/11/09
10/2/09
10092224P
NOV
H1N1
P
DLW
12/7/2009
IM/RA
12/7/09
10/2/09
Afluria
P
06949111A
CSL
TAA
9/12/2010
IM/RA
8/10/10
9/12/10
2F600411
GSK
Flulaval
P
JTA
10/1/2011
IM/LA
8/10/11
10/1/11
3
M50907
CSL
KKC
IIV3
P
9/5/2012
IM/RA
7/2/12
9/5/12
3
PSC
350603F
DCP
RIV3
P
7/26/13
12/2/13
12/2/2013
IM/RA
PMC
JTA
IIV4
P
UI196AA
8/19/14
10/5/14
10/5/2014
IM/RA
NOV
111773P
DCP
IIV4
P
8/7/15
11/2/15
11/2/2015
IM/LA
Pneumococcal conjugate
PCV13
P
7-5096-o6A
WYE
CJP
11/1/2012
IM/LA
4/16/10
11/1/12
3
663012/1163X
MSD
PPSV23
P
DLW
9/10/2011
IM/LA
10/6/09
9/10/11
Pneumococcal polysac-
charide
663860/1626X
PPSV23
MSD
P
TAA
9/15/2015
IM/LA
4/24/15
9/15/15
3
Zoster
3
D05561
PMC
P
MAT
ActHIB
11/1/2014
IM/RA
2/4/14
11/1/14
Hib
3
Other
See page 1
Abbreviation
Trade Name and Manufacturer
How to Complete this Record
Immunization Action Coalition Saint Paul, Minnesota 651 - 647 - 9009 www.immunize.org www.vaccineinformation.org
p
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