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Vaccine Administration Record For Adults

Vaccine Administration Record
Patient name: ______________________________
for Adults
Birthdate: _________________________________
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). Update the patient’s personal record card or provide a new one whenever you administer vaccine.
Type of
Vaccine
Vaccine Information
Signature/
Vaccine
Date given Source
Vaccine1
Site3
Statement
initials of
(mo/day/yr)
(F,S,P)2
(generic abbreviation)
Lot #
Mfr.
Date on VIS4
Date given4
vaccinator
Tetanus,
Diphtheria, Pertussis
(e.g., Td, Tdap)
Give IM.
Hepatitis A5
(e.g., HepA, HepA-HepB)
Give IM.
Hepatitis B5
(e.g., HepB, HepA-HepB)
Give IM.
Human papillomavirus
(HPV)
Give IM.
Measles, Mumps,
Rubella
(MMR) Give SC.
Varicella
(Var) Give SC.
Pneumococcal,
polysaccharide (PPV)
Give SC or IM.
Meningococcal
(e.g., MCV4, conjugate;
MPSV4, polysaccharide)
Give MCV4 IM.
Give MPSV4 SC.
Zoster (Zos) Give SC.
Influenza
(e.g., TIV, inactivated;
LAIV, live, attenuated)
Give TIV IM.
Give LAIV IN.
Other
Other
1. Record the generic abbreviation for the type of vaccine given (e.g., PPV,
3. Record the site where vaccine was administered as either RA (Right Arm),
HepA-HepB), not the trade name.
LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal).
2. Record the source of the vaccine given as either F (Federally-supported), S
4. Record the publication date of each VIS as well as the date it is given to the
(State-supported), or P (supported by Private insurance or other Private funds).
patient.
5. For combination vaccines, fill in a row for each separate antigen in the com-
bination.
Technical content reviewed by the Centers for Disease Control and Prevention, February 2008.
www.immunize.org/catg.d/p2023.pdf • Item #P2023 (2/08)
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record
Patient name: ______________________________
Mohammed Sharik
for Adults
Birthdate: _________________________________
April 15, 1978
Chart number: ______________________________
06-132543
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). Update the patient’s personal record card or provide a new one whenever you administer vaccine.
Type of
Vaccine
Vaccine Information
Signature/
Vaccine
Date given Source
Vaccine1
Site3
Statement
initials of
(mo/day/yr)
(F,S,P)2
(generic abbreviation)
Lot #
Mfr.
Date on VIS4
Date given4
vaccinator
Tetanus,
Td
8/01/02
P
LA
U0376AA
AVP
6/10/94
8/01/02
JTA
Diphtheria, (Pertussis)
Td
9/01/02
P
LA
U0376AA
AVP
6/10/94
9/01/02
PWS
(e.g., Td, Tdap)
Give IM.
Td
3/01/03
P
LA
U0376AA
AVP
6/10/94
3/01/03
TAA
Tdap
1/07/08
P
LA
C2454AA
SPI
7/12/06
1/07/08
JTA
1 shot, 2 different VIS dates
Hepatitis A5
HepA-HepB
8/01/02
P
RA
HAB239A4
GSK
8/25/98
8/01/02
JTA
(e.g., HepA, HepA-HepB)
Give IM.
HepA-HepB
9/01/02
P
RA
HAB239A4
GSK
8/25/98
9/01/02
TAA
HepA-HepB
2/01/03
P
RA
HAB239A4
GSK
8/25/98
2/01/03
TAA
Hepatitis B5
HepA-HepB
8/01/02
P
RA
HAB239A4
GSK
7/11/01
8/01/02
JTA
(e.g., HepB, HepA-HepB)
Give IM.
HepA-HepB
9/01/02
P
RA
HAB239A4
GSK
7/11/01
9/01/02
TAA
HepA-HepB
2/01/03
P
RA
HAB239A4
GSK
7/11/01
2/01/03
TAA
Human Papillomavirus
(HPV)
Give IM.
Measles, Mumps,
MMR
8/01/02
P
RA
0025L
MRK
6/13/02
8/01/02
JTA
Rubella
(MMR) Give SC.
MMR
11/01/02
P
RA
0025L
MRK
6/13/02
11/01/02
PWS
Varicella
(Var) Give SC.
Pneumococcal,
PPV
10/01/02
P
LA
0443A
MRK
7/29/97
10/01/02
TAA
polysaccharide (PPV)
Give SC or IM.
Meningococcal
MCV4
10/9/06
P
RA
U1766AA
SPI
10/7/05
10/9/06
KKC
(e.g., MCV4, conjugate;
MPSV4, polysaccharide)
Give MCV4 IM.
Give MPSV4 SC.
Zoster (Zos) Give SC.
Influenza
TIV
10/01/02
P
RA
U088211
AVP
6/26/02
10/01/02
PWS
(e.g., TIV, inactivated;
TIVEx
LAIV, live, attenuated)
ample
10/10/03
P
LA
U091145
AVP
5/6/03
10/10/03
DLW
Give TIV IM.
TIV
10/8/04
P
RA
U100461
AVP
5/24/04
10/08/04
TAA
Give LAIV IN.
TIV
10/12/05
P
LA
U101059
SPI
7/18/05
10/12/05
JTA
TIV
10/9/06
P
LA
71211
NOV
6/30/06
10/9/06
KKC
TIV
MAT
(This is a record for a 29-year-old healthcare worker with diabetes who
is planning to travel to Saudi Arabia for the annual Hajj.)
How to record combination vaccines
Other
given to adults (i.e., HepA-HepB)
Other
1. Record the generic abbreviation for the type of vaccine given (e.g.,
3. Record the site where vaccine was administered as either RA (Right Arm),
PPV, HepA-HepB), not the trade name.
LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal).
2. Record the source of the vaccine given as either F (Federally-supported),
4. Record the publication date of each VIS as well as the date it is given to the
S (State-supported), or P (supported by Private insurance or other
patient.
Private funds).
5. For combination vaccines, fill in a row for each separate antigen in the
combination.
Technical content reviewed by the Centers for Disease Control and Prevention, February 2008.
www.immunize.org/catg.d/p2023.pdf • Item #P2023 (2/08)
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org