Form P2023 "Vaccine Administration Record for Adults"

What Is Form P2023?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention on August 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form P2023 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention.

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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
Vaccine
Date vaccine
Funding
Route
3
Vaccinator
5
Statement (VIS)
Type of
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
Site
3
Lot #
Mfr.
Date on VIS
4
Date given
4
initials and title)
2
Tetanus,
Diphtheria, Pertussis
(e.g., Tdap, Td)
Give IM.
3
Hepatitis A
(e.g., HepA, HepA-HepB
6
)
Give IM.
3
Hepatitis B
1
(e.g.,
Engerix-B, Recombi-
vax HB, Heplisav-B, HepA-HepB
6
)
Give IM.
3
Human papillomavirus
(HPV2*, HPV4*, HPV9)
Give IM.
3
Measles, Mumps, Rubella
(MMR) Give Subcut.
3
Varicella (chickenpox,VAR)
Give Subcut.
3
Meningococcal ACWY
(e.g., MenACWY, MPSV4*)
Give MenACWY IM.
3
Meningococcal B
(e.g., MenB)
Give MenB IM.
3
*HPV2, HPV4, and MPSV4 vaccines are no longer available in the U.S., but should be included in patient records for historical purposes.
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. With the exception of hepatitis B vaccines, record the generic abbrevia-
Tdap
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
tion (e.g., Tdap) or the trade name for each vaccine; for hepatitis B vac-
HepA
Havrix (GSK); Vaqta (Merck)
cines, record the trade name (see table at
right).
For hepatitis B,
Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax)
2. Record the funding source of the vaccine given as either F (federal),
see footnote #1.
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 [SC]), intradermal (ID), intranasal (NAS), or
HPV4*, HPV9
Gardasil, Gardasil 9 (Merck)
oral (PO) and also the site where it was administered as either RA (right
MMR
MMRII (Merck)
arm), 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)
MenB
Bexsero (GSK); Trumenba (Pfizer)
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.
continued on the next page ▶
6. For combination vaccines, fill in a row for each antigen in the combination.
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf
Item #P2023 (8/18)
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
Vaccine
Date vaccine
Funding
Route
3
Vaccinator
5
Statement (VIS)
Type of
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
Site
3
Lot #
Mfr.
Date on VIS
4
Date given
4
initials and title)
2
Tetanus,
Diphtheria, Pertussis
(e.g., Tdap, Td)
Give IM.
3
Hepatitis A
(e.g., HepA, HepA-HepB
6
)
Give IM.
3
Hepatitis B
1
(e.g.,
Engerix-B, Recombi-
vax HB, Heplisav-B, HepA-HepB
6
)
Give IM.
3
Human papillomavirus
(HPV2*, HPV4*, HPV9)
Give IM.
3
Measles, Mumps, Rubella
(MMR) Give Subcut.
3
Varicella (chickenpox,VAR)
Give Subcut.
3
Meningococcal ACWY
(e.g., MenACWY, MPSV4*)
Give MenACWY IM.
3
Meningococcal B
(e.g., MenB)
Give MenB IM.
3
*HPV2, HPV4, and MPSV4 vaccines are no longer available in the U.S., but should be included in patient records for historical purposes.
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. With the exception of hepatitis B vaccines, record the generic abbrevia-
Tdap
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
tion (e.g., Tdap) or the trade name for each vaccine; for hepatitis B vac-
HepA
Havrix (GSK); Vaqta (Merck)
cines, record the trade name (see table at
right).
For hepatitis B,
Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax)
2. Record the funding source of the vaccine given as either F (federal),
see footnote #1.
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 [SC]), intradermal (ID), intranasal (NAS), or
HPV4*, HPV9
Gardasil, Gardasil 9 (Merck)
oral (PO) and also the site where it was administered as either RA (right
MMR
MMRII (Merck)
arm), 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)
MenB
Bexsero (GSK); Trumenba (Pfizer)
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.
continued on the next page ▶
6. For combination vaccines, fill in a row for each antigen in the combination.
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf
Item #P2023 (8/18)
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
Vaccine
Date vaccine
Funding
Route
3
Vaccinator
5
Statement (VIS)
Type of
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
Site
3
Lot #
Mfr.
Date on VIS
4
Date given
4
initials and title)
2
Influenza
(e.g., IIV3, IIV4, ccIIV4,
RIV3, RIV4, LAIV4)
Give IIV3, IIV4, ccIIV3,
RIV3, and RIV4 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 (shingles)
Give RZV IM
3
Give ZVL Subcut
3
Hib Give IM.
3
Other
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella,
Abbreviation
Trade Name and Manufacturer
MenACWY, and MenB vaccines.
IIV3/IIV4 (inactivated influenza vaccine,
Fluarix, FluLaval (GSK); Afluria, Fluad, Flu-
How to Complete this Record
trivalent or quadrivalent); ccIIV4 (cell
celvax, Fluvirin (Seqirus); Flublok, Fluzone,
culture-based inactivated influenza
Fluzone Intradermal, Fluzone High-Dose
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
vaccine, quadrivalent); RIV3/RIV4
(Sanofi Pasteur)
vaccine (see table at right).
(inactivated recombinant influenza
vaccine, trivalent or quadrivalent)
2. Record the funding source of the vaccine given as either F (federal),
S (state), or P (private).
LAIV (live attenuated influenza
FluMist (MedImmune)
vaccine, quadrivalent]
3. Record the route by which the vaccine was given as either intramuscular
PCV13
Prevnar 13 (Pfizer)
(IM), subcutaneous (Subcut [SC]), intradermal (ID), intranasal (NAS), or
PPSV23
Pneumovax 23 (Merck)
oral (PO) and also the site where it was administered as either RA (right
RZV (recombinant zoster vaccine)
Shingrix, RZV (GSK);
arm), LA (left arm), RT (right thigh), or LT (left thigh).
ZVL (zoster vaccine, live)
Zostavax, ZVL (Merck)
4. Record the publication date of each VIS as well as the date the VIS is
Hib
ActHIB (Sanofi Pasteur); Hiberix (GSK);
given to the patient.
PedvaxHib (Merck)
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.
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 (8/18)
page 1 0f 2
Vaccine Administration Record
Patient name
Mike Schultz
for Adults
Birthdate
5/31/1967
Chart number 010406
practice name and address
Before administering any vaccines, give the patient copies of all pertinent
Small Rural Clinic
Vaccine Information Statements (VISs) and make sure he/she understands
135 County Road 42
the risks and benefits of the vaccine(s). Always provide or update the patient’s
Smallville, IN 46902
personal record card.
Vaccine Information
Date vaccine
Funding
Route
Vaccine
3
Vaccinator
5
Statement (VIS)
Type of
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
Site
initials and title)
2
3
Lot #
Mfr.
Date on VIS
4
Date given
4
Td
8/1/02
P
U0376AA
AVP
6/10/94
8/1/02
JTA
LA
IM/
Tetanus,
Diphtheria, Pertussis
Td
9/1/02
P
IM/LA
U0376AA
AVP
6/10/94
9/1/02
RVO
(e.g., Tdap, Td)
Td
3/1/03
P
U0376AA
AVP
3/1/03
3/1/03
TAA
IM/LA
Give IM.
3
Tdap
3/1/15
P
IM/LA
AC52B009AA
GSK
2/24/15
3/1/15
JTA
Hepatitis A
(e.g., HepA, HepA-HepB
6
)
Give IM.
3
Heplisav-B
2/5/18
P
LA
TDG007
DVX
7/20/16
2/5/18
TAA
IM/
Hepatitis B
1
(e.g.,
Engerix-B, Recombi-
Heplisav-B
3/12/18
P
IM/LA
TDG007
DVX
7/20/16
3/12/18
TAA
vax HB, Heplisav-B, HepA-HepB
)
6
Give IM.
3
Human papillomavirus
(HPV2*, HPV4*, HPV9)
Give IM.
3
MMR
8/1/02
P
0025L
MSD
6/13/02
8/1/02
JTA
Measles, Mumps, Rubella
SC/RA
(MMR) Give Subcut.
3
MMR
11/1/02
P
SC/RA
0025L
MSD
6/13/02
11/1/02
TAA
VAR
8/1/02
P
0799M
MSD
12/16/98
8/1/02
JTA
SC/LA
Varicella (chickenpox,VAR)
Give Subcut.
3
VAR
11/1/02
P
SC/LA
0799M
MSD
12/16/98
11/1/02
TAA
MenACWY
7/12/11
P
M28011
NOV
3/2/08
7/12/11
RVO
Meningococcal ACWY
IM/RA
(e.g., MenACWY, MPSV4*)
Menveo
7/15/16
P
IM/LA
M12115
NOV
3/31/16
7/15/16
RVO
Give MenACWY IM.
3
MenB
1/14/16
P
J296203
PFR
8/14/15
1/14/16
RVO
IM/LA
Meningococcal B
(e.g., MenB)
Trumenba
9/15/16
P
IM/LA
J296203
PFR
8/14/15
9/15/16
RVO
Give MenB IM.
3
*HPV2, HPV4, and MPSV4 vaccines are no longer available in the U.S., but should be included in patient records for historical purposes.
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. With the exception of hepatitis B vaccines, record the generic abbrevia-
Tdap
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
tion (e.g., Tdap) or the trade name for each vaccine; for hepatitis B vac-
HepA
Havrix (GSK); Vaqta (Merck)
cines, record the trade name (see table at
right).
For hepatitis B,
Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax)
2. Record the funding source of the vaccine given as either F (federal),
see footnote #1.
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 [SC]), intradermal (ID), intranasal (NAS), or
HPV4*, HPV9
Gardasil, Gardasil 9 (Merck)
oral (PO) and also the site where it was administered as either RA (right
MMR
MMRII (Merck)
arm), 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.
continued on the next page ▶
6. For combination vaccines, fill in a row for each antigen in the combination.
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf
Item #P2023 (8/18)
page 2 0f 2
Vaccine Administration Record
Mike Schultz
Patient name
for Adults
5/31/1967
Chart number 010406
Birthdate
(continued)
practice name and address
Before administering any vaccines, give the patient copies of all pertinent
Small Rural Clinic
Vaccine Information Statements (VISs) and make sure he/she understands
135 County Road 42
the risks and benefits of the vaccine(s). Always provide or update the patient’s
Smallville, IN 46902
personal record card.
Vaccine Information
Date vaccine
Funding
Route
Vaccine
3
Vaccinator
5
Statement (VIS)
Type of
Vaccine
given
Source
and
(signature or
Vaccine
1
Lot #
Mfr.
Date on VIS
Date given
(mo/day/yr)
(F,S,P)
2
Site
3
4
4
initials and title)
Flulaval
10/2/09
P
RA
2F600411
GSK
8/11/09
10/2/09
PWS
Influenza
IM/
(e.g., IIV3, IIV4, ccIIV4,
H1N1
12/7/09
P
IM/RA
10092224P
NOV
10/2/09
12/7/09
DLW
RIV3, RIV4, LAIV4)
Afluria
9/12/10
P
IM/RA
06949111A
NOV
8/10/10
9/12/10
TAA
Give IIV3, IIV4, ccIIV3,
Flulaval
10/1/11
P
IM/LA
2F750345
GSK
8/10/11
10/1/11
JTA
RIV3, and RIV4 IM.
3
IIV3
9/5/12
P
IM/RA
M50907
CSL
7/2/12
9/5/12
KKC
Give LAIV4 NAS.
3
RIV3
12/2/13
P
IM/RA
350603F
PSC
7/26/13
12/2/13
DCP
IIV4
10/5/14
P
IM/RA
UI196AA
PMC
8/19/14
10/5/14
JTA
IIV4
11/2/15
P
IM/LA
123773P
NOV
8/7/15
11/2/15
DCP
IIV4
10/1/16
P
IM/LA
U1206AA
PMC
8/7/15
10/1/16
TAA
ccIIV4
9/30/17
P
IM/LA
185128
SEQ
8/7/15
9/30/17
RVO
Pneumococcal conjugate
PCV13
11/1/12
P
RA
7-5096-06A
WYE
4/16/10
11/1/12
CJP
IM/
3
(e.g., PCV13) Give PCV13 IM.
PPSV23
9/12/10
P
RA
663012/1163X
MSD
10/6/09
9/12/10
TAA
Pneumococcal polysac-
IM/
charide (e.g., PPSV23)
PPSV23
11/2/15
P
IM/RA
663012/1163X
MSD
10/6/09
11/2/15
DCP
Give PPSV23 IM or
Subcut.
3
Zoster (shingles)
RZV
3/15/18
P
RA
A1283
GSK
2/12/18
3/15/18
CJP
IM/
Give RZV IM
3
Shingrix
5/17/18
P
IM/RA
A1283
GSK
2/12/18
5/17/18
CJP
Give ZVL Subcut
3
ActHIB
11/1/12
P
RA
DO5561
PMC
4/16/10
11/1/12
CJP
IM/
Hib Give IM.
3
Other
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella,
Abbreviation
Trade Name and Manufacturer
MenACWY, and MenB vaccines.
IIV3/IIV4 (inactivated influenza vaccine,
Fluarix, FluLaval (GSK); Afluria, Fluad, Flu-
How to Complete this Record
trivalent or quadrivalent); ccIIV4 (cell
celvax, Fluvirin (Seqirus); Flublok, Fluzone,
culture-based inactivated influenza
Fluzone Intradermal, Fluzone High-Dose
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
vaccine, quadrivalent); RIV3/RIV4
(Sanofi Pasteur)
vaccine (see table at right).
(inactivated recombinant influenza
vaccine, trivalent or quadrivalent)
2. Record the funding source of the vaccine given as either F (federal),
S (state), or P (private).
LAIV (live attenuated influenza
FluMist (MedImmune)
vaccine, quadrivalent]
3. Record the route by which the vaccine was given as either intramuscular
PCV13
Prevnar 13 (Pfizer)
(IM), subcutaneous (Subcut [SC]), intradermal (ID), intranasal (NAS), or
PPSV23
Pneumovax 23 (Merck)
oral (PO) and also the site where it was administered as either RA (right
RZV (recombinant zoster vaccine)
Shingrix, RZV (GSK);
arm), LA (left arm), RT (right thigh), or LT (left thigh).
ZVL (zoster vaccine, live)
Zostavax, ZVL (Merck)
4. Record the publication date of each VIS as well as the date the VIS is
ActHIB (Sanofi Pasteur); Hiberix (GSK);
Hib
given to the patient.
PedvaxHib (Merck)
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.
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 (8/18)
Page of 4