Adult Immunization Record Form PDF Details

An Adult Immunization Record is an essential tool designed to keep track of vaccinations for adults, ensuring they are up-to-date with their immunizations. This detailed form captures a wide array of information, beginning with basic personal details like last name, first name, middle initial, gender, date of birth, and mother’s maiden name. For healthcare providers, it's a pivotal document that includes the clinic's name and address, emphasizing the importance of accessible patient vaccination records. By federal law, specific information such as the vaccine type, the manufacturer, lot number, route and site of administration, dosage, the administrator's signature and title, and dates regarding when the vaccine was given and the Vaccine Information Statement (VIS) was provided, must be meticulously logged. This record not only facilitates the provision of information required under the National Childhood Vaccine Injury Act for adult vaccinations but also aids in monitoring adherence to recommended immunization schedules. It outlines the appropriate method to record combination vaccines, injection routes, and sites, which is crucial for effective vaccine delivery and minimizing adverse reactions. Furthermore, the form provides guidance on how to document vaccine reactions and transferring immunization information, ensuring a comprehensive vaccination history that can be shared across healthcare providers. It also introduces the Minnesota Immunization Information Connection (MIIC) and underscores the importance of manufacturer codes for accurate vaccine identification. Ultimately, the Adult Immunization Record serves as a vital document for managing and promoting the health and wellness of individuals through vaccination.

QuestionAnswer
Form NameAdult Immunization Record Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesMIIC, minnesota adult immunization record, adult immunization record, immunization records for adults

Form Preview Example

ADULT IMMUNIZATION RECORD

Last name:

First:

M.I.:

Gender:

Date of birth: ____/____/______

Mother’s maiden name:

 

 

Clinic name and address:

1This information is required by federal law.

2Give Vaccine Information Statement (VIS) to vaccinee, parent, or authorized representative for each routinely recommended vaccine.

Vaccine

Type of vaccine

 

Date given1

Mftr1

Lot#1

Route

Site

Dosage

Signature and title of vaccine administrator1

Date on bottom

Date VIS given to

Hx of vaccine

Given elsewhere

 

MO/DAY/YR

(see back)

RA/LA/LT/RT

of VIS1

patient1,2

reaction (ü)

(ü)

 

 

 

 

 

 

 

Diphtheria, Tetanus,

 

1

 

 

 

IM

 

 

 

 

 

 

 

Pertussis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles, Mumps, Rubella

 

1

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A

 

1

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B

 

1

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Human Papillomavirus

 

1

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

IM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inluenza

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

 

 

 

 

 

 

IM ITN

 

 

 

 

 

 

 

Meningococcal

 

 

 

 

 

IM SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM SC

 

 

 

 

 

 

 

Pneumococcal

 

 

 

 

 

IM SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IM SC

 

 

 

 

 

 

 

Varicella

 

1

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zoster

 

1

 

 

 

SC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minnesota Immunization Program: 651-201-5503 or 1-800-657-3970

www.health.state.mn.us/immunize

IC#140-0497 (3/13)

How to use MDH’s Adult Immunization Record form

Make this record easily accessible

Keep each patient’s immunization record where you can easily review it during each ofice visit (e.g., the front inside cover of the patient’s medical

chart).

Patient behind schedule?

Flag the record if the patient is behind on recommended immunizations.

Record type of vaccine

Be sure to indicate the type of vaccine you gave. This is especially important when you give Tdap rather than Td since persons who receive Td will be at higher risk of pertussis disease if there is a pertussis outbreak in the community.

What information is required by federal law?

You are required by federal law to record the following information as part of the National Childhood Vaccine Injury Act, even though you are administering vaccines to adult patients:

Manufacturer and lot number of vaccine given.

Date vaccine given.

Date of publication of the Vaccine Information Statement (VIS) and the date the VIS was given to the vaccinee.

Name, title, and address of the person who administered the vaccine.

Note: Federal and Minnesota laws do not require written informed consent. However, some clinics may have their own policy.

How to record combination vaccines

Record a combination vaccine under each speciic antigen that the vaccine contains. Use a hyphen between each antigen. For example:

Twinrix is HepA-Hep B. Record it under both HepatitisAand Hepatitis B.

How to record injection routes and sites

The most common routes for vaccination are intramuscular (IM) and subcutaneous (SC or SQ). Less frequent routes include oral (PO) and intranasal (ITN). If there is more than one choice for route, circle the route given. Sites for injections should be noted as to which limb and what side. These include right arm (RA) and left arm (LA), and when necessary, right thigh (RT) and left thigh (LT).

Immunization Program P.O. Box 64975

St. Paul, MN 55164-0975

651-201-5503 or 1-800-657-3970 www.health.state.mn.us/immunize

Hx of vaccine reaction (history of vaccine reaction)

If the patient has experienced a clinically signiicant or unexpected event after an immunization (even if there is uncertainty that the vaccine caused

the event), place a ü in the “Hx of vaccine reaction” column. Provide more speciics about that event elsewhere in the patient’s chart. Report vaccine

reactions to the Vaccine Adverse Events Reporting System (http://vaers.hhs.gov or 800-822-7967).

Transferring immunization information onto this form

Transfer vaccine information that patients receive at other clinics to this record. If you don’t know all of the information, record at least the date (mo/ day/yr) and type of vaccine. The responsibility for maintaining the federally required information is with the clinic that administered the vaccine. Be sure to place a ü in the “Given elsewhere” column. If a patient transfers to another clinic, provide a photocopy to the new clinic.

Use the MIIC registry to record and ind immunizations

If you’re participating in the Minnesota Immunization Information Connection (MIIC), be sure to enter or submit data on new shots for this patient so it is available to others who may be giving subsequent doses. MIIC is located at https://miic.health.state.mn.us. If you are not yet participating, call

800-657-3970, or visit www.health.state.mn.us/immunize (click on “MIIC

Registry”) to ind out how to enroll.

Manufacturers’ codes

Use the codes listed in the chart below to indicate the manufacturer of the vaccine. These are the same codes used universally and by the Minnesota Immunization Information Connection (MIIC).

Vaccine Manufacturer

Code

CSL Biotherapies

CSL

 

 

GlaxoSmithKline

SKB

 

 

Massachusetts Biologic Labs

MBL

 

 

MedImmune, Inc.

MED

 

 

Merck & Co., Inc.

MSD

 

 

Novartis

NOV

 

 

sanoi pasteur Inc.

PMC

Pizer Vaccines

WAL

Your patients need personal immunization record cards

Always update the patient’s personal immunization record with information on the vaccines that you administered. If your clinic needs personal immunization record cards, order the MDH Gold Card by calling 800-657-3970, or 651-201-

5503, or by illing out the order form at www.health.state.mn.us/immunize.