Vaccination Record Form PDF Details

In the intricate fabric of public health, the Vaccination Record form stands as a vital document designed for the meticulous recording and tracking of vaccinations administered to children and teens. This comprehensive form, endorsed by the Immunization Action Coalition and reviewed by the Centers for Disease Control and Prevention, serves multiple critical functions. It ensures that prior to the administration of any vaccines, the child's parent or legal representative is provided with all pertinent Vaccine Information Statements (VISs), essential for understanding the potential risks and benefits of the vaccine(s) in question. Furthermore, this form facilitates the accurate documentation of each vaccine administered, including the vaccine's type, date of administration, the funding source (whether federal, state, or private), and the specific site of administration on the patient's body. To aid in the efficient management of space constraints and fulfill federal documentation requirements, healthcare settings are encouraged to keep a reference list of vaccinators, including their initials and titles. Notably, the form also addresses the administration specifics for various vaccines, including the method of administration (intramuscular, subcutaneous, or oral), and provides a structured format for recording combination vaccines. Additionally, the form is not limited to routine childhood vaccines but extends to include those for measles-mumps-rubella, varicella, hepatitis A, meningococcal disease, human papillomavirus, influenza, and others, potentially including travel vaccines. By ensuring a standardized approach to documenting vaccine administration, this form plays a crucial role in safeguarding individual and public health.

QuestionAnswer
Form NameVaccination Record Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesimmunization record card, children vaccine record, printable immunization card, vaccine record form printable

Form Preview Example

Vaccine Administration Record for Children and Teens

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 beneits of the vaccine(s). Always provide or update the patient’s personal record card.

PAGE 1 0F 2

Patient name

Birthdate

Chart number

 

 

 

 

PRACTICE NAME AND ADDRESS

 

 

 

 

 

 

 

Type of

Date vaccine

Funding

 

Vaccine

 

Vaccine Information

Vaccinator5

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B6

 

 

 

 

 

 

 

 

 

(e.g., HepB, Hib-HepB,

 

 

 

 

 

 

 

 

 

DTaP-HepB-IPV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Give IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diphtheria, Tetanus,

 

 

 

 

 

 

 

 

 

Pertussis6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(e.g., DTaP, DTaP/Hib,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP-HepB-IPV, DT,

 

 

 

 

 

 

 

 

 

DTaP-IPV/Hib, DTaP-IPV,

 

 

 

 

 

 

 

 

 

Tdap, Td) Give IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haemophilus inluenzae

 

 

 

 

 

 

 

 

 

type b6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(e.g., Hib, Hib-HepB,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP-IPV/Hib, DTaP/Hib,

 

 

 

 

 

 

 

 

 

Hib-MenCY) Give IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Polio6

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

DTaP-IPV/Hib, DTaP-IPV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Give IPV Subcut or IM.7

 

 

 

 

 

 

 

 

 

Give all others IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal

 

 

 

 

 

 

 

 

 

(e.g., PCV7, PCV13,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

conjugate; PPSV23,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

polysaccharide)

 

 

 

 

 

 

 

 

 

Give PCV IM.7 Give

 

 

 

 

 

 

 

 

 

PPSV Subcut or IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rotavirus (RV1, RV5)

 

 

 

 

 

 

 

 

 

Give orally (po).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, inluenza, 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 NAS (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, ill in a row for each antigen in the combination.

7.IM is the abbreviation for intramuscular; Subcut is the abbreviation for subcutaneous.

Abbreviation

Trade Name and Manufacturer

 

 

DTAP

Daptacel (Sanoi Pasteur); Infanrix (GlaxoSmithKline [GSK]);

Tripedia (Sanoi Pasteur)

 

DT (pediatric)

Generic (Sanoi Pasteur)

DTaP-HepB-IPV

Pediarix (GSK)

DTaP-IPV/Hib

Pentacel (Sanoi Pasteur)

DTaP-IPV

Kinrix (GSK); Quadracel (Sanoi Pasteur)

HEPB

Engerix-B (GSK); Recombivax HB (Merck)

HEPA-HEPB

Twinrix (GSK); can be given to teens age 18 and older

Hib

ActHIB (Sanoi Pasteur); Hiberix (GSK); PedvaxHIB (Merck)

Hib-MenCY

MenHibrix (GSK)

IPV

Ipol (Sanoi Pasteur)

PCV13

Prevnar 13 (Pizer)

PPSV23

Pneumovax 23 (Merck)

RV1

Rotarix (GSK)

RV5

RotaTeq (Merck)

Tdap

Adacel (Sanoi Pasteur); Boostrix (GSK)

Td

Decavac, Tenivac (Sanoi Pasteur); Generic (MA Biological Labs)

Technical content reviewed by the Centers for Disease Control and Prevention

IMMUNIZATION ACTION COALITION Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org

www.immunize.org/catg.d/P2022.pdf Item #P2022 (4/16)

Vaccine Administration Record for Children and Teens (continued)

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 beneits of the vaccine(s). Always provide or update the patient’s personal record card.

PAGE 2 0F 2

Patient name

Birthdate

Chart number

 

 

 

 

PRACTICE NAME AND ADDRESS

 

 

 

 

 

 

 

Type of

Date vaccine

Funding

 

Vaccine

 

Vaccine Information

Vaccinator5

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)

Measles, Mumps, Rubella6

(e.g., MMR, MMRV)

Give Subcut.7

Varicella6 (e.g., VAR,

MMRV) Give Subcut.7

Hepatitis A (HepA)

Give IM.7

Meningococcal ACWY; CY

(e.g., MenACWY [MCV4];

Hib-MenCY)

Give MenACWY and

Hib-MenCY IM.7

Meningococcal B (e.g.,

MenB) Give MenB IM.7

Human papillomavirus (e.g., HPV2, HPV4, HPV9) Give IM.7

Inluenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4)

Give IIV3, IIV4, ccIIV3, and RIV3 IM.7

Give LAIV4 NAS.7

Other

See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus inluenzae 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 NAS (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, ill in a row for each antigen in the combination.

7.IM is the abbreviation for intramuscular; Subcut is the abbreviation for subcutaneous.

Abbreviation

Trade Name and Manufacturer

 

 

MMR

MMRII (Merck)

VAR

Varivax (Merck)

MMRV

ProQuad (Merck)

HEPA

Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck)

HEPA-HEPB

Twinrix (GSK)

HPV2

Cervarix (GSK)

HPV4, HPV9

Gardasil, Gardasil 9 (Merck)

LAIV4 (live attenuated inlu-

FluMist (MedImmune)

enza vaccine, quadrivalent)

 

IIV3 (inactivated inluenza vac-

 

cine, trivalent), IIV4 (inactivated

 

inluenza vaccine, quadrivalent),

Fluarix (GSK); Flublok (Protein Sciences Corp.);

ccIIV3 (cell culture-based

Aluria, Fluad, Flucelvax, Fluvirin (Seqirus);

inactivated inluenza vaccine,

FluLaval (GSK); Fluzone (Sanoi Pasteur)

trivalent), RIV3 (inactivated

 

recombinant inluenza vaccine,

 

trivalent)

 

 

 

MenACWY

Menactra (Sanoi Pasteur); Menveo (GSK)

HibMenCY

MenHibrix (GSK)

MenB

Bexsero (GSK); Trumenba (Pizer)

IMMUNIZATION ACTION COALITION Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org

www.immunize.org/catg.d/P2022.pdf Item #P2022 – page 2 (4/16)

Vaccine Administration Record for Children and Teens

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 beneits of the vaccine(s). Always provide or update the patient’s personal record card.

PAGE 1 0F 2

Patient name SAMANTHA JO SWENSON

Birthdate

6/1/2010

Chart number

 

PRACTICE NAME AND ADDRESS

Metropolitan Pediatrics

6547 Grand Avenue

Big City, AB 35791

 

Type of

Date vaccine

Funding

 

Vaccine

 

Vaccine Information

 

Vaccinator5

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B6

HepB

6/2/2010

P

IM/RT

0651M

MRK

7/18/07

6/2/2010

 

JTA

(e.g., HepB, Hib-HepB,

Pediarix

8/2/2010

F

IM/RT

635A1

GSK

7/18/07

8/2/2010

 

DCP

DTaP-HepB-IPV)

 

Pediarix

10/2/2010

F

IM/RT

712A2

GSK

7/18/07

10/2/2010

 

DCP

Give IM.7

 

 

Pediarix

12/2/2010

F

IM/RT

712A2

GSK

7/18/07

12/2/2010

 

DLW

 

 

 

 

 

 

 

 

 

 

 

Diphtheria, Tetanus,

Pediarix

8/2/2010

F

IM/RT

635A1

GSK

5/17/07

8/2/2010

 

DCP

Pertussis6

 

 

 

 

 

 

 

 

 

 

Pediarix

10/2/2010

F

IM/RT

712A2

GSK

5/17/07

10/2/2010

 

DCP

(e.g., DTaP, DTaP/Hib,

 

 

 

 

 

 

 

 

 

 

 

Pediarix

12/2/2010

F

IM/RT

712A2

GSK

5/17/07

12/2/2010

 

DLW

DTaP-HepB-IPV, DT,

 

 

 

 

 

 

 

 

 

 

 

DTaP-IPV/Hib, DTaP-IPV,

DTaP

9/2/2011

F

IM/RT

365922

PMC

5/17/07

9/2/2010

 

RLV

Tdap, Td) Give IM.7

 

 

 

 

 

 

 

 

 

 

DTaP

8/2/2015

F

IM/RA

376912

PMC

5/17/07

8/2/2015

 

JTA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

+DHPRSKL XVLQƬXHQ]DH

Hib

8/2/2010

F

IM/RT

1492L

MSD

12/16/98

8/2/2010

 

DCP

type b6

 

 

 

 

 

 

 

 

 

 

Hib

10/2/2010

F

IM/RT

1492L

MSD

12/16/98

10/2/2010

 

DCP

(e.g., Hib, Hib-HepB,

 

 

 

 

 

 

 

 

 

 

Hib

12/2/2010

F

IM/RT

1492L

MSD

12/16/98

12/2/2010

 

DLW

DTaP-IPV/Hib, DTaP/Hib,

 

Hib-MenCY) Give IM.7

Hib

9/2/2011

F

IM/LT

1543L

MSD

12/16/98

9/2/2011

 

RLV

 

 

 

 

 

 

 

 

 

 

 

Polio6

Pediarix

8/2/2010

F

IM/RT

635A1

GSK

1/1/00

8/2/2010

 

DCP

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

Pediarix

10/2/2010

F

IM/RT

712A2

GSK

1/1/00

10/2/2010

 

DCP

DTaP-IPV/Hib, DTaP-IPV)

 

 

 

 

 

 

 

 

 

 

 

Pediarix

12/2/2010

F

IM/RT

712A2

GSK

1/1/00

12/2/2010

 

DLW

Give IPV Subcut or IM.7

 

 

 

Give all others IM.7

IPV

8/2/2015

F

IM/LA

U4569-8

PMC

11/8/11

8/2/2015

 

RLV

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal

PCV13

8/2/2010

F

IM/LT

7-5095-05A

WYE

4/16/10

8/2/2010

 

DCP

(e.g., PCV7, PCV13,

 

 

 

 

 

 

 

 

 

 

PCV13

10/2/2010

F

IM/LT

7-5095-05A

WYE

4/16/10

10/2/2010

 

DCP

conjugate; PPSV23,

 

 

 

 

 

 

 

 

 

 

PCV13

12/2/2010

F

IM/LT

7-5095-05A

WYE

4/16/10

12/2/2010

 

DLW

polysaccharide)

 

Give PCV IM.7 Give

PCV13

9/2/2011

F

IM/LT

7-5095-05A

WYE

4/16/10

9/2/2010

 

RLV

PPSV Subcut or IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rotavirus (RV1, RV5)

RV5

8/2/2010

F

PO

05849

MSD

5/14/10

8/2/2010

 

DCP

Give orally (po).

 

 

 

 

 

 

 

 

 

 

RotaTeq

10/2/2010

F

PO

05849

MSD

5/14/10

10/2/2010

 

DCP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RotaTeq

12/2/2010

F

PO

05849

MSD

5/14/10

12/2/2010

 

DLW

 

 

 

 

 

 

 

 

 

 

 

See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, inluenza, 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 NAS (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, ill in a row for each antigen in the combination.

7.IM is the abbreviation for intramuscular; Subcut is the abbreviation for subcutaneous.

Abbreviation

Trade Name and Manufacturer

 

 

DTAP

Daptacel (Sanoi Pasteur); Infanrix (GlaxoSmithKline [GSK]);

Tripedia (Sanoi Pasteur)

 

DT (pediatric)

Generic (Sanoi Pasteur)

DTaP-HepB-IPV

Pediarix (GSK)

DTaP-IPV/Hib

Pentacel (Sanoi Pasteur)

DTaP-IPV

Kinrix (GSK); Quadracel (Sanoi Pasteur)

HEPB

Engerix-B (GSK); Recombivax HB (Merck)

HEPA-HEPB

Twinrix (GSK); can be given to teens age 18 and older

Hib

ActHIB (Sanoi Pasteur); Hiberix (GSK); PedvaxHIB (Merck)

Hib-MenCY

MenHibrix (GSK)

IPV

Ipol (Sanoi Pasteur)

PCV13

Prevnar 13 (Pizer)

PPSV23

Pneumovax 23 (Merck)

RV1

Rotarix (GSK)

RV5

RotaTeq (Merck)

Tdap

Adacel (Sanoi Pasteur); Boostrix (GSK)

Td

Decavac, Tenivac (Sanoi Pasteur); Generic (MA Biological Labs)

Technical content reviewed by the Centers for Disease Control and Prevention

IMMUNIZATION ACTION COALITION Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org

www.immunize.org/catg.d/P2022.pdf Item #P2022 (4/16)

Vaccine Administration Record for Children and Teens (continued)

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 beneits of the vaccine(s). Always provide or update the patient’s personal record card.

PAGE 2 0F 2

Patient name SAMANTHA JO SWENSON

Birthdate

6/1/2010

Chart number

 

PRACTICE NAME AND ADDRESS

Metropolitan Pediatrics

6547 Grand Avenue

Big City, AB 35791

 

Type of

Date vaccine

Funding

 

 

Vaccine

 

Vaccine Information

Vaccinator5

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles, Mumps, Rubella6

MMRV

7/2/2011

F

Subcut/RA

 

0857M

MSD

5/21/10

7/2/2010

DLW

(e.g., MMR, MMRV)

 

 

 

 

 

 

 

 

 

 

MMRV

8/2/2015

F

 

 

0522F

MSD

 

 

DCP

Give Subcut.7

Subcut/LA

 

5/21/10

8/2/2015

 

 

 

 

 

 

 

 

 

 

 

Varicella6 (e.g., VAR,

MMRV

7/2/2011

F

Subcut/RA

 

0857M

MSD

5/21/10

7/2/2010

DLW

MMRV) Give Subcut.7

MMRV

8/2/2015

F

Subcut/LA

 

05ssF

MSD

5/21/10

8/2/2015

DCP

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A (HepA)

Havrix

7/2/2011

F

IM/LA

 

AHAVB944

GSK

3/21/06

7/2/2010

DLW

Give IM.7

 

 

 

 

 

 

 

 

 

 

Vaqta

1/5/2012

F

IM/LA

 

0634K

MSD

3/21/06

1/5/2011

TAA

 

 

 

 

 

 

 

 

 

 

 

 

 

Meningococcal ACWY; CY

 

 

 

 

 

 

 

 

 

 

(e.g., MenACWY [MCV4];

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib-MenCY)

 

 

 

 

 

 

 

 

 

 

Give MenACWY and

 

 

 

 

 

 

 

 

 

 

Hib-MenCY IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meningococcal B (e.g.,

 

 

 

 

 

 

 

 

 

 

MenB) Give MenB IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Human papillomavirus

 

 

 

 

 

 

 

 

 

 

(e.g., HPV2, HPV4,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HPV9) Give IM.7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

, Ƭ H ]D (e.g., IIV3, IIV4,

Fluzone

12/2/2010

F

IM/LT

 

U097543

PMC

8/10/10

12/1/2010

DLW

ccIIV3, RIV3, LAIV4)

Fluzone

1/5/2011

F

IM/LT

 

U097543

PMC

8/10/10

1/5/2011

JTA

Give IIV3, IIV4, ccIIV3,

 

 

 

 

 

 

 

 

 

 

 

IIV3

9/15/2011

F

IM/RT

 

U068954

PMC

7/26/11

9/15/2011

TAA

and RIV3 IM.7

 

Give LAIV4 NAS.7

LAIV3

9/2/2012

F

NAS

 

500491P

MED

7/2/2012

9/10/2012

RLV

 

FluMist

9/15/2013

F

NAS

 

65431P

MED

7/26/2013

9/15/2013

JTA

 

 

 

 

 

 

 

 

 

 

 

 

Fluarix (IIV4)

10/1/2014

F

IM/RT

 

J5G53

GSK

8/19/2014

10/1/2014

DCP

 

 

 

 

 

 

 

 

 

 

 

 

LAIV4

9/10/2015

F

NAS

 

78591P

MED

8/7/2015

9/10/2015

DLW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus

L Ƭ H ]DHtype 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 NAS (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, ill in a row for each antigen in the combination.

7.IM is the abbreviation for intramuscular; Subcut is the abbreviation for subcutaneous.

Abbreviation

Trade Name and Manufacturer

 

 

MMR

MMRII (Merck)

VAR

Varivax (Merck)

MMRV

ProQuad (Merck)

HEPA

Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck)

HEPA-HEPB

Twinrix (GSK)

HPV2

Cervarix (GSK)

HPV4, HPV9

Gardasil, Gardasil 9 (Merck)

LAIV4 (live attenuated inlu-

FluMist (MedImmune)

enza vaccine, quadrivalent)

 

IIV3 (inactivated inluenza vac-

 

cine, trivalent), IIV4 (inactivated

 

inluenza vaccine, quadrivalent),

Fluarix (GSK); Flublok (Protein Sciences Corp.);

ccIIV3 (cell culture-based

Aluria, Fluad, Flucelvax, Fluvirin (Seqirus);

inactivated inluenza vaccine,

FluLaval (GSK); Fluzone (Sanoi Pasteur)

trivalent), RIV3 (inactivated

 

recombinant inluenza vaccine,

 

trivalent)

 

 

 

MenACWY

Menactra (Sanoi Pasteur); Menveo (GSK)

HibMenCY

MenHibrix (GSK)

MenB

Bexsero (GSK); Trumenba (Pizer)

IMMUNIZATION ACTION COALITION Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org

www.immunize.org/catg.d/P2022.pdf Item #P2022 – page 2 (4/16)

How to Edit Vaccination Record Form Online for Free

You are able to fill in vaccination records easily using our PDFinity® editor. In order to make our editor better and simpler to utilize, we consistently implement new features, with our users' suggestions in mind. In case you are seeking to begin, here's what it requires:

Step 1: Firstly, access the editor by pressing the "Get Form Button" at the top of this page.

Step 2: This tool offers you the ability to customize PDF forms in various ways. Transform it by writing personalized text, correct original content, and include a signature - all at your fingertips!

It is simple to complete the form using this helpful guide! Here is what you should do:

1. When filling out the vaccination records, ensure to incorporate all needed blank fields in their relevant form section. This will help to speed up the work, which allows your information to be handled promptly and appropriately.

Filling in segment 1 of immunization record card

2. Right after completing the last section, go on to the subsequent part and fill out the essential details in these blanks - Haemophilus inluenzae type b eg, Polio eg IPV DTaPHepBIPV, Pneumococcal eg PCV PCV conjugate, Rotavirus RV RV Give orally po, See page to record, meningococcal HPV inluenza and, How to Complete this Record, vaccine see table at right, Record the funding source of the, S state or P private, Record the site where vaccine was, Abbreviation, DTaP, DT pediatric DTaPHepBIPV, and HepAHepB Hib HibMenCY IPV PCV PPSV.

The best ways to fill out immunization record card stage 2

3. This next part will be focused on Immunization Action Coalition, and wwwimmunizeorgcatgdppdf Item P - complete all of these fields.

Immunization Action Coalition, Immunization Action Coalition, and wwwimmunizeorgcatgdppdf  Item P in immunization record card

4. This next section requires some additional information. Ensure you complete all the necessary fields - Vaccine Administration Record for, Before administering any vaccines, page f, Patient name, Birthdate Chart number, practice name and address, Type of Vaccine, Date vaccine, given, modayyr, Funding Source FSP, Site, Vaccine, Vaccine Information, and Statement VIS - to proceed further in your process!

How one can fill in immunization record card stage 4

5. The document needs to be completed by dealing with this part. Here you will find an extensive set of form fields that need appropriate details to allow your document usage to be complete: Meningococcal ACWY CY eg MenACWY, Meningococcal B eg MenB Give MenB, Human papillomavirus eg HPV HPV, Inluenza eg IIV IIV ccIIV RIV LAIV, and Other.

Meningococcal B eg MenB Give MenB, Inluenza eg IIV IIV ccIIV RIV LAIV, and Meningococcal ACWY CY eg MenACWY of immunization record card

Be extremely attentive when filling in Meningococcal B eg MenB Give MenB and Inluenza eg IIV IIV ccIIV RIV LAIV, as this is where most users make some mistakes.

Step 3: Just after looking through the filled in blanks, hit "Done" and you're good to go! After starting afree trial account at FormsPal, you will be able to download vaccination records or email it promptly. The PDF will also be easily accessible in your personal account page with your edits. FormsPal ensures your information confidentiality with a protected method that in no way saves or distributes any private data involved. You can relax knowing your files are kept confidential each time you work with our service!