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(Page 1 of 2)

Vaccine Administration Record for Adults

Patient name: ______________________________ 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). Always provide or update the patient's personal record card.

Vaccine

Tetanus, Diphtheria, Pertussis (e.g., Td, Tdap) Give IM.6

Type of Vaccine1

Date given

(mo/day/yr)

Funding source Site3 (F,S,P)2

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Hepatitis A7 (e.g., HepA, HepA-HepB) Give IM.6 Hepatitis B7 (e.g., HepB, HepA-HepB) Give IM.6 Human papillomavirus (HPV2, HPV4) Give IM.6 Measles, Mumps, Rubella (MMR) Give SC.6 Varicella (VAR) Give SC.6

Pneumococcal polysaccharide (PPSV23) Give SC or IM.6 Meningococcal (e.g., MCV4, conjugate; MPSV4, polysaccharide) Give MCV4 IM.6 Give MPSV4 SC.6

See page 2 to record influenza, zoster, 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. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. 7. For combination vaccines, fill in a row for each antigen in the combination.

Abbreviation

Tdap Td HepA HepB HepA-HepB HPV2 HPV4 MMR VAR PPSV23 MCV4 MPSV4

Trade Name & Manufacturer

Adacel (sanofi pasteur), Boostrix (GlaxoSmithKline [GSK]) Decavac (sanofi pasteur), generic (MA Biological Labs) Havrix (GSK); Vaqta (Merck) Engerix-B (GSK), Recombivax HB (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) MMRII (Merck) Varivax (Merck) Pneumovax 23 (Merck) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

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

For additional copies, visit www.immunize.org/catg.d/p2023.pdf · Item #P2023 (3/11)

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

(Page 2 of 2)

Vaccine Administration Record for Adults

Patient name: ______________________________ 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). Always provide or update the patient's personal record card.

Vaccine

Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.6 Give LAIV IN.6

Type of Vaccine1

Date given

Funding Source Site3 (mo/day/yr) (F,S,P)2

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Zoster (ZOS) Give SC.6 Other

See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal 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), IN (intranasal), or . 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. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal.

Abbreviation

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

Trade Name & Manufacturer

FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi pasteur); Fluzone High-Dose (sanofi pasteur) Zostavax (Merck)

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

For additional copies, visit www.immunize.org/catg.d/p2023.pdf · Item #P2023 (3/11)

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

(Page 1 of 2)

Vaccine Administration Record for Adults

Patient name: MohammedSharik Birthdate:4/14/1981 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). Always provide or update the patient's personal record card.

Vaccine

Tetanus, Diphtheria, Pertussis (e.g., Td, Tdap) Give IM.6

Type of Vaccine1

Date given

(mo/day/yr)

Funding source Site3 (F,S,P)2

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

Hepatitis A7 (e.g., HepA, HepA-HepB) Give IM.6 Hepatitis B7 (e.g., HepB, HepA-HepB) Give IM.6 Human papillomavirus (HPV2, HPV4) Give IM.6 Measles, Mumps, Rubella (MMR) Give SC.6 Varicella (VAR) Give SC.6

Td Td Td Tdap HepA-HepB HepA-HepB HepA-HepB HepA-HepB HepA-HepB HepA-HepB

8/01/02 9/1/2002 3/1/2003 6/14/2010 8/1/2002 9/1/2002 3/1/2003 8/1/2002 9/1/2002 3/1/2003

P P P P P P P P P P

LA LA LA LA RA RA RA RA RA RA

U0376AA U0376AA U0376AA AC52B030AA HAB239A4 HAB239A4 HAB239A4 HAB239A4 HAB239A4 HAB239A4

AVP AVP AVP GSK GSK GSK GSK GSK GSK GSK

6/10/94 6/10/94 6/10/94 11/18/2008 8/25/1998 8/25/1998 8/25/1998 7/11/2001 7/11/2001 7/11/2001

8/1/2002 9/1/2002 3/1/2003 6/14/2010 8/1/2002 9/1/2002 3/1/2003 8/1/2002 9/1/2002 3/1/2003

JTA PWS TAA JTA JTA PWS TAA JTA PWS TAA

1shot,2differentVISdates MMR MMR VAR VAR Menveo 8/1/2002 11/1/2002 8/1/2002 11/1/2002 P P P P RA RA LA RA 0025L 0025L 0799M 0689M MRK MRK MRK MRK 6/13/2002 8/1/2002 6/13/2002 11/1/2002 12/16/1998 8/1/2002 12/16/199811/1/2002 JTA TAA JTA TAA JTA

Pneumococcal polysaccharide (PPSV23) Give SC or IM. Meningococcal

6

(e.g., MCV4, conjugate; MPSV4, polysaccharide) Give MCV4 IM.6 Give MPSV4 SC.6

7/12/2010

See page 2 to record influenza, zoster, and other vaccines (e.g., travel vaccines).

How to Complete this Record

ple am Ex

P RA 28011 NOV 1/28/2008 7/12/2010

Abbreviation

Tdap Td HepA HepB HepA-HepB HPV2 HPV4 MMR VAR PPSV23 MCV4 MPSV4

Trade Name & Manufacturer

Adacel (sanofi pasteur), Boostrix (GlaxoSmithKline [GSK]) Decavac (sanofi pasteur), generic (MA Biological Labs) Havrix (GSK); Vaqta (Merck) Engerix-B (GSK), Recombivax HB (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) MMRII (Merck) Varivax (Merck) Pneumovax 23 (Merck) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

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. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. 7. For combination vaccines, fill in a row for each antigen in the combination.

Thisisarecordfora29-year-oldhealthcareworkerwhois planningtotraveltoSaudiArabiafortheannualHajj.

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

For additional copies, visit www.immunize.org/catg.d/p2023.pdf · Item #P2023 (3/11)

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

(Page 2 of 2)

Vaccine Administration Record for Adults

Patient name: MohammedSharik Birthdate:4/14/1981 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). Always provide or update the patient's personal record card.

Vaccine

Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.6 Give LAIV IN.6

Type of Vaccine1

Date given

Funding Source Site3 (mo/day/yr) (F,S,P)2

Vaccine

Lot # Mfr.

Vaccine Information Statement (VIS)

Date on VIS4 Date given4

Vaccinator5

(signature or initials & title)

TIV 11/1/2002 TIV10/10/2003 Fluzone10/8/2004 TIV11/12/2005 Fluvirin 10/9/2006 Flumist11/15/2007 Afluria10/12/2008 Flulaval 10/2/2009 H1N1 12/7/2009 Includesspacetorecordvaccines givenforinternationaltravel. Oraltyphoid7/12/2010x4

Zoster (ZOS) Give SC.6 Other

ple am Ex

P po TXE355 BER

Abbreviation

LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) ZOS (shingles) FluMist (MedImmune) Zostavax (Merck)

P P P P P P P P F

RA LA RA LA LA IN RA LA RA

U088211 U091145 U100461 U2169MA 878771P 500337P 06949111A 2F600411 1009224P

AVP AVP AVP SPI NOV MED CSL GSK NOV

6/26/2002 5/6/2003 5/24/2004 7/18/2005 6/30/2006 7/16/2007 7/24/2008 8/11/2009 10/2/2009

11/1/2002 10/10/2003 10/8/2004 11/12/2005 10/9/2006 11/15/2007 10/12/2008 10/2/2009 12/7/2009

PWS DLW TAA JTA KKC DCP JTA DCP DLW

5/19/2004 7/12/2010

MAT

See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal 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. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal.

Trade Name & Manufacturer

Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi pasteur); Fluzone High-Dose (sanofi pasteur)

Thisisarecordfora29-year-oldhealthcareworkerwhois planningtotraveltoSaudiArabiafortheannualHajj.

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

For additional copies, visit www.immunize.org/catg.d/p2023.pdf · Item #P2023 (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 Adults

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