Vaccine Administration Record PDF

PAG E 1 0 F 2 Vaccine Administration Record Pat...

PAG E 1 0 F 2 Vaccine Administration Record Patient name Birthdate Chart number for Adults practice name and address Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure they understand the risks and benefits of the vaccine(s). Always provide or update the patient’s personal record card. Date vaccine Funding Vaccine Information Vaccinator5 Type of Vaccine Vaccine given Source Site3 Statement (VIS) (signature or Vaccine1 (mo/day/yr) (F,S,P)2 Lot # Mfr. Date on VIS4 Date given4 initials and title) Tetanus, Diphtheria, Pertussis (e.g., Tdap, Td) Give IM.3 Hepatitis A6 (e.g., HepA, HepA-HepB) Give IM.3 Hepatitis B6 (e.g., HepB, HepA-HepB) Give IM.3 Human papillomavirus (HPV) Give IM.3 Measles, Mumps, Rubella (MMR) Give MMRII Subcut or IM; give Priorix Subcut.3 Varicella (VAR) Give Subcut or IM.3 Meningococcal ACWY (MenACWY) Give MenACWY IM.3 Meningococcal B (e.g., MenB-4C, MenB- FHbp) Give MenB IM.3 c o n t i n u ed o n t h e bac k Abbreviation Trade Name and Manufacturer How to Complete this Record Tdap Adacel (Sanofi); Boostrix (GSK) 1. For hepatitis B and meningococcal B vaccines, record the trade name (see table Td Tenivac (Sanofi); Tdvax (MA Biological Labs) at right); for all other vaccines, record the standard abbreviation (e.g., Tdap). HepA Havrix (GSK); Vaqta (Merck) 2. Record the funding source of the vaccine given as either F (federal), S (state), or Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax); P (private). HepB (see note #1) PreHevbrio (VBI) 3. Record the route by which the vaccine was given as either intramuscular (IM), HepA-HepB Twinrix (GSK) subcutaneous (Subcut), or intranasal (NAS), and also the site where it was admin- HPV Gardasil 9 (Merck) istered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh). MMR MMR II (Merck); Priorix (GSK) 4. Record the publication date of each VIS as well as the date the VIS is given to VAR Varivax (Merck) the patient. MenACWY MenQuadfi (Sanofi); Menveo (GSK) 5. To meet the space constraints of this form and federal requirements for MenB-4C (see note #1) Bexsero (GSK) documentation, a healthcare setting should keep a reference list of vaccinators MenB-FHbp that includes their initials and titles. Trumenba (Pfizer) (see note #1) 6. For combination vaccines, fill in a row for each antigen in the combination. www.immunize.org/catg.d/p2023.pdf FOR PROFESSIONALS www.immunize.org / FOR THE PUBLIC www.vaccineinformation.org Item #P2023 (9/18/2023) Scan for PDF  PAG E 2 0 F 2 Vaccine Administration Record Patient name for Adults (continued) 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 they understand the risks and benefits of the vaccine(s). Always provide or update the patient’s personal record card. Vaccine Information Vaccinator5 Date vaccine Funding Vaccine (signature or Type of Statement (VIS) Vaccine Vaccine1 given Source Site3 initials and title) (mo/day/yr) (F,S,P)2 Lot # Mfr. Date on VIS4 Date given4 Pneumococcal conjugate (e.g., PCV13, PCV15, PCV20) Give IM.3 Pneumococcal polysac- charide (e.g., PPSV23) Give IM or Subcut.3 Influenza (IIV, ccIIV, RIV, LAIV) Give IIV, ccIIV, and RIV IM.3 Give LAIV NAS.3 Zoster (shingles) Give RZV IM.3 COVID-19 (e.g., COV-mRNA; COV-aPS) Give IM.3 Hib Give IM.3 RSV Give IM.3 Other Abbreviation Trade Name and Manufacturer How to Complete this Record Prevnar 13 (Pfizer); Vaxneuvance (Merck); 1. For RSV and COVID-19 vaccines, record the trade name (see table at right); PCV13, PCV15, PCV20 Prevnar 20 (Pfizer) for all other vaccines, record the standard abbreviation (e.g., RZV) or the PPSV23 Pneumovax 23 (Merck) trade name for each vaccine (see table at right). aIIV (adjuvanted inactivated influenza Fluad (GSK) vaccine [IIV]) 2. Record the funding source of the vaccine given as either F (federal), ccIIV (cell culture-based IIV) Flucelvax (Seqirus) S (state), or P (private). HD-IIV (high-dose IIV) Fluzone High-Dose (Sanofi) 3. Record the route by which the vaccine was given as either intramuscular LAIV (live attenuated influenza vaccine] FluMist (AstraZeneca) (IM), subcutaneous (Subcut), or intranasal (NAS), and also the site where it RIV (recombinant influenza vaccine) Flublok (Sanofi) was administered as either RA (right arm), LA (left arm), SD-IIV (standard dose IIV) Fluarix, FluLaval (GSK); Afluria (Seqirus); RT (right thigh), or LT (left thigh). Fluzone (Sanofi) RZV (recombinant zoster vaccine) Shingrix (GSK) 4. Record the publication date of each VIS as well as the date the VIS is given Comirnaty (Pfizer-BioNTech); to the patient. COV-mRNA (see note #1) Spikevax (Moderna) 5. To meet the space constraints of this form and federal requirements for COV-aPS (see note #1) Novavax (Novavax) documentation, a healthcare setting should keep a reference list of ActHIB (Sanofi); Hiberix (GSK); Hib vaccinators that includes their initials and titles. PedvaxHib (Merck) RSV (respiratory syncytial virus vaccine) Arexvy (GSK); Abrysvo (Pfizer) (see note #1) www.immunize.org/catg.d/p2023.pdf / Item #P2023 (9/18/2023)