Adult Immunization Record Form – Fill Out and Use This PDF

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.

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.