Read Vaccine Administration Record for Children and Teens text version

Vaccine Administration Record for Children and Teens

Patient name: Birthdate: Chart number:

(Page 1 of 2)

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative 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

Hepatitis B6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.7

Type of Vaccine1

Date given Funding Source (mo/day/yr) (F,S,P)2

Site3

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Diphtheria, Tetanus, Pertussis6 (e.g., DTaP, DTaP/Hib, DTaP-HepB-IPV, DT, DTaP-IPV/Hib, Tdap, DTaP-IPV, Td) Give IM.7

Haemophilus influenzae type b6 (e.g., Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib) Give IM.7

6

Polio (e.g., IPV, DTaP-HepB-IPV,

DTaP-IPV/Hib, DTaP-IPV) Give IPV SC or IM.7 Give all others IM.7 Pneumococcal (e.g., PCV7, PCV13, conjugate; PPSV23, polysaccharide) Give PCV IM.7 Give PPSV SC or IM.7 Rotavirus (RV1, RV5) Give orally (po).

See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, 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 site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal). 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. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous.

Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.

Abbreviation

DTaP DT (pediatric) DTaP-HepB-IPV DTaP/Hib DTaP-IPV/Hib DTaP-IPV HepB HepA-HepB Hib Hib-HepB IPV PCV13 PPSV23 RV1 RV5 Tdap Td

Trade Name & Manufacturer

Daptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur) Generic (sanofi pasteur) Pediarix (GSK) TriHIBit (sanofi pasteur) Pentacel (sanofi pasteur) Kinrix (GSK) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck) Comvax (Merck) Ipol (sanofi pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (sanofi pasteur); Boostrix (GSK) Decavac (sanofi pasteur), Generic (MA Biological Labs)

For additional copies, visit www.immunize.org/catg.d/p2022.pdf · Item #P2022 (3/11)

This form was created by the Immunization Action Coalition · www.immunize.org · www.vaccineinformation.org

Vaccine Administration Record for Children and Teens

Funding Source (F,S,P)2

Patient name: Birthdate: Chart number:

(Page 2 of 2)

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative 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

Measles, Mumps, Rubella6 (e.g., MMR, MMRV) Give SC.7 Varicella6 (e.g., VAR, MMRV) Give SC.7 Hepatitis A (HepA) Give IM.7

Type of Vaccine1

Date given

(mo/day/yr)

Site3

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM7 and MPSV4 SC.7 Human papillomavirus (e.g., HPV2, HPV4) Give IM.7 Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.7 Give LAIV IN.7

Other

See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus 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 site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal). 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. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal.

Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.

Abbreviation

MMR VAR MMRV HepA HepA-HepB HPV2 HPV4

LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine)

Trade Name & Manufacturer

MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck)

FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi)

MCV4 MPSV4

Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

For additional copies, visit www.immunize.org/catg.d/p2022.pdf · Item #P2022 (3/11)

This form was created by the Immunization Action Coalition · www.immunize.org · www.vaccineinformation.org

Vaccine Administration Record for Children and Teens

Patient name: Birthdate: Chart number:

Emily Jacobs 6/2/2005

(Page 1 of 2)

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative 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

Hepatitis B6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.7

Type of Vaccine1

Date given Funding Source (mo/day/yr) (F,S,P)2

Site3

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

HepB Pediarix Pediarix DTaP-HepB-IPV(Pediarix) Pediarix Pediarix Diphtheria, Tetanus, Pertussis Pediarix (e.g., DTaP, DTaP/Hib, Pediarix DTaP-HepB-IPV, DT, DTaP-IPV/Hib, Tdap, DTaP-Hib DTaP-IPV, Td) DTaP Give IM.

6 7

6/2/2005 F RT 0651M MRK 8/2/2005 F RT 635A1 GSK 10/2/2005 F RT 712A2 GSK 12/2/2005 F RT 712A2 GSK 8/2/2005 F RT 635A2 GSK 10/2/2005 F RT 712A2 GSK 12/2/2005 F RT 712A2 GSK 9/2/2006 F RA P0897AA SPI 8/2/2010 F RA 326-912 SPI DTaP-Hib(TriHIBit):2lot#s,2differentVISs 8/2/2005 10/2/2005 12/2/2005 9/2/2006 8/2/2005 10/2/2005 12/2/2005 8/2/2010 8/2/2005 10/2/2005 12/2/2005 9/2/2006 8/2/2010 F F F F F F F F F F F F F LT LT LT RA RT RT RT RA LT RT LT LA LA UA744AA UA744AA UA744AA 7172AA 635A2 712A2 712A2 U4569-8 489-835 489-835 489-835 501-245 E44433 SPI SPI SPI SPI GSK GSK GSK SPI WYE WYE WYE WYE PFI

7/11/01 6/2/05 JTA 7/11/01 8/2/05 DCP 7/11/01 10/2/05 DCP 7/11/01 12/2/05 DLW 7/30/01 8/2/05 DCP 7/30/01 10/2/05 DCP 7/30/01 12/2/05 DLW 7/30/01 9/2/06 RLV 5/17/07 8/2/10 JTA Pediarix:3differentVISdates 12/16/98 12/16/98 12/16/98 12/16/98 1/1/00 1/1/00 1/1/00 1/1/00 9/30/02 9/30/02 9/30/02 9/30/02 12/9/08 8/2/05 10/2/05 12/2/05 9/2/06 8/2/05 10/2/05 12/2/05 8/2/10 8/2/05 10/2/05 12/2/05 9/2/06 8/2/10 DCP DCP DLW RLV DCP DCP DLW DCP DCP DCP DLW RLV DCP

Haemophilus influen- zae type b (e.g., Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib) Give IM. Polio (e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV7, PCV13, con- jugate; PPSV23, polysaccharide) Give PCV IM. Give PPSV SC or IM.

6 7 6 7 7 7 7

Rotavirus (RV1, RV5) Give orally (po).

See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, 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).

ple am Ex

Abbreviation

DTaP DT (pediatric) DTaP-HepB-IPV DTaP/Hib DTaP-IPV/Hib DTaP-IPV HepB HepA-HepB Hib Hib-HepB IPV PCV13 PPSV23 RV1 RV5 Tdap Td

Hib Hib Hib DTaP-Hib Pediarix Pediarix Pediarix IPV PCV7 PCV7 PCV7 PCV7 PCV13

Trade Name & Manufacturer

Daptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur) Generic (sanofi pasteur) Pediarix (GSK) TriHIBit (sanofi pasteur) Pentacel (sanofi pasteur) Kinrix (GSK) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck) Comvax (Merck) Ipol (sanofi pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (sanofi pasteur); Boostrix (GSK) Decavac (sanofi pasteur), Generic (MA Biological Labs)

3. Record the site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal). 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. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous.

Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.

For additional copies, visit www.immunize.org/catg.d/p2022.pdf · Item #P2022 (3/11)

This form was created by the Immunization Action Coalition · www.immunize.org · www.vaccineinformation.org

Vaccine Administration Record for Children and Teens

Funding Source (F,S,P)2

Patient name: Birthdate: Chart number:

Emily Jacobs 6/2/2005

(Page 2 of 2)

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative 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

Measles, Mumps, Rubella6 (e.g., MMR, MMRV) Give SC.7 Varicella6 (e.g., VAR, MMRV) Give SC.7 Hepatitis A (HepA) Give IM.7

Type of Vaccine1

Date given

(mo/day/yr)

Site3

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM7 and MPSV4 SC.7 Human papillomavirus (e.g., HPV2, HPV4) Give IM.7 Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.7 Give LAIV IN.7

MMRV MMRV MMRV MMRV HepA HepA

MMR-VAR(MMRV) TIV TIV TIV LAIV TIV TIV TIV-H1N1 LAIV-H1N1

ple am Ex

12/5/2005 1/5/2006 10/16/2006 11/15/2007 10/12/2008 10/2/2009 11/15/2009 12/29/2009 F F F S S F F F RT RT LA IN RA LA RA IN U097543 U097543 U106459 500337P U2169MA 71211 UP016AA 500756P SPI SPI SPI MED SPI NOV SPI MED

6/2/2006 8/2/2010 6/2/2006 8/2/2010 6/2/2006 12/2/2006

P P P P P P

RA LA RA LA LA LA

0857M 0522F 0857M 0522F 0524L 0634K

MRK MRK MRK MRK MRK MRK

1/15/03 5/21/10 12/16/98 5/21/10 8/4/04 3/21/06

6/2/06 8/2/10 6/2/06 8/2/10 6/2/06 8/2/06

DLW DCP DLW DCP DLW MAT

7/18/05 12/5/05 7/18/05 1/5/06 6/30/06 10/16/06 7/16/07 11/15/07 7/24/08 10/12/08 8/11/09 10/2/09 10/2/0911/15/09 10/2/09 12/29/09

JTA DCP MAT ABB CAS MAT CEL ZAZ

Other

See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus 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 site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal). 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. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal.

Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.

Abbreviation

MMR VAR MMRV HepA HepA-HepB HPV2 HPV4

LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine)

Trade Name & Manufacturer

MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck)

FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi)

MCV4 MPSV4

Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

For additional copies, visit www.immunize.org/catg.d/p2022.pdf · Item #P2022 (3/11)

This form was created by the Immunization Action Coalition · www.immunize.org · www.vaccineinformation.org

Vaccine Administration Record for Children and Teens

Patient name: Birthdate: Chart number:

Jessica Ashley 10/15/1991

(Page 1 of 2)

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative 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

Hepatitis B6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.7

Type of Vaccine1

Date given Funding Source (mo/day/yr) (F,S,P)2

Site3

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

HepB(1.0mL) 6/2/2004 P RA 0651M HepB(1.0mL) 1/2/2005 P RA 0651M 2-doseseriesofadultRecombivaxgiventochild12-15yrs DTP 12/15/1991 P RT 326-912 Diphtheria, Tetanus, Pertussis DTP 2/15/1992 P RT 326-912 (e.g., DTaP, DTaP/Hib, DTaP 4/15/1992 P RT 326-912 DTaP-HepB-IPV, DT, DTaP-IPV/Hib, Tdap, DTaP 4/15/1993 P RA 326-912 DTaP-IPV, Td) DTaP 4/15/1996 P RA 657-888 Give IM. Td 10/15/2003 P RA 467-854 Tdap 6/12/2010 P RAAC52B023AA Hib 12/15/1991 P LT 1492L Haemophilus influen- zae type b PedvaxHIB 2/15/1992 P LT 1492L (e.g., Hib, Hib-HepB, Hib 10/15/1992 P LT 1492L DTaP-IPV/Hib, DTaP/Hib) Give IM. OPV 12/15/1991 P po 0678A Polio (e.g., IPV, DTaP-HepB-IPV, OPV 2/15/1992 P po 0678A DTaP-IPV/Hib, DTaP-IPV) OPV 4/15/1993 P po 0678A Give IPV SC or IM. Give all others IM. OPV 4/15/1996 P po 0987A Pneumococcal

6 7 6 7 6 7 7

MRK 7/11/01 MRK 7/11/01 LED LED LED LED LED LED GSK MRK MRK MRK LED LED LED LED 1/1/88 10/15/91 3/25/92 3/25/92 6/10/94 7/30/01 11/18/08 6/6/91 6/6/91 6/6/91 10/15/91 10/15/91 10/15/91 10/15/91

6/2/04 1/2/05 12/15/91 2/15/92 4/15/92 4/15/93 4/15/96 10/15/03 6/12/10 12/15/91 2/15/92 10/15/92 12/15/91 2/15/92 4/15/93 4/15/93

TAA TAA DCP DCP DLW RLV JTA PWS DLW DCP DCP DLW DCP DCP RLV JTA

(e.g., PCV7, PCV13, conjugate; PPSV23, polysaccharide) Give PCV IM.7 Give PPSV SC or IM.7 Rotavirus (RV1, RV5) Give orally (po).

ple xam E

Abbreviation

DTaP DT (pediatric) DTaP-HepB-IPV DTaP/Hib DTaP-IPV/Hib DTaP-IPV HepB HepA-HepB Hib Hib-HepB IPV PCV13 PPSV23 RV1 RV5 Tdap Td

See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, 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 site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal). 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. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous.

Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.

Trade Name & Manufacturer

Daptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur) Generic (sanofi pasteur) Pediarix (GSK) TriHIBit (sanofi pasteur) Pentacel (sanofi pasteur) Kinrix (GSK) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck) Comvax (Merck) Ipol (sanofi pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (sanofi pasteur); Boostrix (GSK) Decavac (sanofi pasteur), Generic (MA Biological Labs)

For additional copies, visit www.immunize.org/catg.d/p2022.pdf · Item #P2022 (3/11)

This form was created by the Immunization Action Coalition · www.immunize.org · www.vaccineinformation.org

Vaccine Administration Record for Children and Teens

Funding Source (F,S,P)2

Patient name: Birthdate: Chart number:

Jessica Ashley 10/15/1991

(Page 2 of 2)

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative 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

Measles, Mumps, Rubella6 (e.g., MMR, MMRV) Give SC.7 Varicella6 (e.g., VAR, MMRV) Give SC.7 Hepatitis A (HepA) Give IM.7

Type of Vaccine1

Date given

(mo/day/yr)

Site3

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM7 and MPSV4 SC.7 Human papillomavirus (e.g., HPV2, HPV4) Give IM.7 Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.7 Give LAIV IN.7

MMR MMR VAR VAR MCV4 HPV2 Cervarix Garadasil FluMist TIV Fluzone H1N1

1/15/1993 10/15/2003 10/15/2003 10/15/2007 6/12/2010 12/12/2009 2/13/2010 6/12/2010 10/15/2007 10/12/2008 10/2/2009 12/7/2009

P P P P

RA LA LA LA

0857M 0946M 0799M 0689M

MRK MRK MRK MRK

10/15/91 1/15/03 12/16/98 1/10/07

1/15/93 10/15/03 10/15/03 10/15/07

DLW PWS PWS JTA

P P P P P P P P

LA LA LA LA IN RA RA LA

28011 0331Z 0331Z 0637F 500491P 878771P U100461 1009224P

NOV GSK GSK MRK MED NOV SPI NOV

1//28/08 2/2/07 2/2/07 2/2/07 10/4/07 7/24/08 8/11/09 10/2/09

6/12/10 12/12/09 2/13/10 6/12/10 10/15/07 10/12/08 10/2/09 12/7/09

MAT TAA PWS DLW MAT JTA DLW MAT

Whenrecordingthetypeofvaccine,usethegenericabbreviation,tradename,orboth.By recordingthemanufacturer,youwillalwaysbeabletodeterminethebrandofvaccinegiven.

Other

See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus vaccines.

How to Complete this Record

ple am Ex

Abbreviation

MMR VAR MMRV HepA HepA-HepB HPV2 HPV4

LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine)

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 site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or IN (intranasal). 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. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal.

Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.

Trade Name & Manufacturer

MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck)

FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi)

MCV4 MPSV4

Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

For additional copies, visit www.immunize.org/catg.d/p2022.pdf · Item #P2022 (3/11)

This form was created by the Immunization Action Coalition · www.immunize.org · www.vaccineinformation.org

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Vaccine Administration Record for Children and Teens

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