State Form 52642 "Vaccine Administration Record for Children and Teens" - Indiana

What Is State Form 52642?

This is a legal form that was released by the Indiana State Department of Health - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2006;
  • The latest edition provided by the Indiana State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of State Form 52642 by clicking the link below or browse more documents and templates provided by the Indiana State Department of Health.

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Download State Form 52642 "Vaccine Administration Record for Children and Teens" - Indiana

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VACCINE ADMINISTRATION RECORD FOR CHILDREN AND TEENS
State Form 52642 (4-06)
IMMUNIZATION PROGRAM
INSTRUCTIONS 1. Before administering any vaccines, give the parent/guardian all appropriate copies of Vaccine Information Statements (VIS)
and make sure they understand the risks and benefits of the vaccine(s).
2. Update the patient’s personal immunization record card.
3. Record the generic abbreviation for the type of vaccine given (e.g.: DTaP-Hib, PCV), not the trade name.
4. Record the publication date of each VIS as well as the date it is given to the patient.
5. For combination vaccines, fill in a row for each separate antigen in the combination.
6. Give MCV4 via the IM route and MPSV4 via the SC route.
7. Give TIV via the IM route and LAIV intranasally (IN).
Clinic Name/Address
Patient Name: ________________________________
Birth Date:
______________
Record #:
______________
Type of
Date given
Route
Site
Vaccine
Vaccine Information
Signature/
1
Vaccine
vaccine
(mo/day/yr)
given
Statement
initials of
(
(RA, LA,
2
2
vaccinator
Lot #
Mfr.
Expiration
Date on VIS
Date given
generic
RT, LT)
)
Date
abbreviation
3
Hepatitis B
IM
e.g., HepB, Hib-HepB,
IM
DTaP-HepB-IPV
IM
IM
IM
Diptheria, Tetanus,
3
Pertussis
IM
e.g., DTaP, DT, DTaP-Hib,
DTaP-HepB-IPV,
IM
Td, Tdap
IM
IM
IM
IM
Haemophilus
IM
3
influenzae type b
IM
e.g., Hib, Hib-HepB,
DTaP-Hib
IM
IM
3
IM SC
Polio
e.g., IPV, DTaP-HepB-IPV
IM SC
IM SC
IM SC
Pneumococcal
IM
PCV (conjugate)
IM
PPV (polysaccharide)
IM
IM
SC
Measles, Mumps,
3
Rubella
SC
e.g., MMR, MMRV
3
Varicella
SC
e.g., Var, MMRV
SC
Hepatitis A
IM
HepA
IM
4
Meningococcal
MCV4 (conjugate)
MPSV4 (polysaccharide)
Rotavirus
RotaTeq
VACCINE ADMINISTRATION RECORD FOR CHILDREN AND TEENS
State Form 52642 (4-06)
IMMUNIZATION PROGRAM
INSTRUCTIONS 1. Before administering any vaccines, give the parent/guardian all appropriate copies of Vaccine Information Statements (VIS)
and make sure they understand the risks and benefits of the vaccine(s).
2. Update the patient’s personal immunization record card.
3. Record the generic abbreviation for the type of vaccine given (e.g.: DTaP-Hib, PCV), not the trade name.
4. Record the publication date of each VIS as well as the date it is given to the patient.
5. For combination vaccines, fill in a row for each separate antigen in the combination.
6. Give MCV4 via the IM route and MPSV4 via the SC route.
7. Give TIV via the IM route and LAIV intranasally (IN).
Clinic Name/Address
Patient Name: ________________________________
Birth Date:
______________
Record #:
______________
Type of
Date given
Route
Site
Vaccine
Vaccine Information
Signature/
1
Vaccine
vaccine
(mo/day/yr)
given
Statement
initials of
(
(RA, LA,
2
2
vaccinator
Lot #
Mfr.
Expiration
Date on VIS
Date given
generic
RT, LT)
)
Date
abbreviation
3
Hepatitis B
IM
e.g., HepB, Hib-HepB,
IM
DTaP-HepB-IPV
IM
IM
IM
Diptheria, Tetanus,
3
Pertussis
IM
e.g., DTaP, DT, DTaP-Hib,
DTaP-HepB-IPV,
IM
Td, Tdap
IM
IM
IM
IM
Haemophilus
IM
3
influenzae type b
IM
e.g., Hib, Hib-HepB,
DTaP-Hib
IM
IM
3
IM SC
Polio
e.g., IPV, DTaP-HepB-IPV
IM SC
IM SC
IM SC
Pneumococcal
IM
PCV (conjugate)
IM
PPV (polysaccharide)
IM
IM
SC
Measles, Mumps,
3
Rubella
SC
e.g., MMR, MMRV
3
Varicella
SC
e.g., Var, MMRV
SC
Hepatitis A
IM
HepA
IM
4
Meningococcal
MCV4 (conjugate)
MPSV4 (polysaccharide)
Rotavirus
RotaTeq
Type of
Date given
Route
Site
Vaccine
Vaccine Information
Signature/
1
Vaccine
vaccine
(mo/day/yr)
given
Statement
initials of
(
(RA, LA,
2
2
vaccinator
Lot #
Mfr.
Expiration
Date on VIS
Date given
generic
RT, LT)
)
Date
abbreviation
5
Influenza
TIV (inactivated)
LAIV (live, attenuated)
HPV
Other
Adapted from the Immunization Action Coalition Vaccine Administration Record
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