Vaccination Record Form – Fill Out and Use This PDF

The Vaccination Record form serves as a comprehensive tool designed to document and manage the vaccination history for children and teens. It is structured to ensure the capture of critical vaccine-related information including administration dates, vaccine types, funding sources, and sites of administration, along with pertinent Vaccine Information Statements (VISs) provided to the child's parent or legal representative. To ensure the health and safety of young patients and comply with healthcare regulations, it is crucial to diligently fill out and maintain this form by clicking the button below.

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How to Fill Out Vaccine Administration Record for Children and Teens

Vaccine Administration Record for Children and Teens at a glance

What it is: This form is the Vaccine Administration Record for Children and Teens.

Who signs: Vaccinator: signature or initials and title.

A filled-in Vaccine Administration Record for Children and Teens example: a nurse records one hepatitis B dose

Vaccine Administration Record for Children and Teens example filled out, example: a nurse records one hepatitis B dose — A nurse fills out the Vaccine Administration Record for Children and Teens. The nurse records a baby's first hepatitis B dose, given on 03/14/2026. The picture shows page 1, and none of its entries is real. The dose is federally funded, so Funding Source reads F. The dose goes into the right thigh by intramuscular injection, so Route & Site reads IM RT. The Vaccine Information Statement is given on the day of the dose, so both VIS dates are filled.

How to fill out Vaccine Administration Record for Children and Teens, box by box

Patient name, birthdate, chart number and practice name and address

Enter the patient name, birthdate, chart number and practice name and address.

Standard abbreviation or trade name on page 1

Record the standard abbreviation (e.g., Tdap) or the trade name for each vaccine. Use trade name for HepB if vaccinating an older teen (schedule varies by brand).

Trade name or standard abbreviation on page 2

For meningococcal B vaccines and COVID-19 vaccines, record the trade name; for all other vaccines, record the standard abbreviation (e.g., HPV) or trade name for each vaccine.

Date Vaccine Given (mo/day/yr)

Enter the Date Vaccine Given as mo/day/yr.

Funding Source (F,S,P)

2. Record the funding source of the vaccine given as either F (federal), S (state), or P (private).

Route & Site on page 1

Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), or intranasal (NAS), and also the site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal).

Hepatitis B: Give IM.

RSV-mAb: Give IM.

Diphtheria, Tetanus, Pertussis: Give IM.

Haemophilus influenzae type b: Give IM.

Polio: Give IPV Subcut or IM. Give all others IM.

Pneumococcal: Give PCV IM. Give PPSV23 Subcut or IM.

Rotavirus (RV1, RV5): Give orally (po).

Give IM or Subcut on page 2

Measles, Mumps, Rubella: Give MMRII and MMRV Subcut or IM; give Priorix Subcut.

Varicella: Give Subcut or IM.

Hepatitis A: Give IM.

Meningococcal ACWY: Give IM.

Meningococcal B: Give IM.

Human papillomavirus (HPV): Give IM.

Influenza: Give IIV, ccIIV, and RIV IM. Give LAIV NAS.

COVID-19: Give IM.

Publication date of each VIS

4. Record the publication date of each VIS as well as the date the VIS is given to the patient.

Reference list of vaccinators with initials and titles

To meet the space constraints of this form and federal requirements for documentation, a healthcare setting should keep a reference list of vaccinators that includes their initials and titles.

If your situation is different

The vaccine is a combination vaccine

6. For combination vaccines, fill in a row for each antigen in the combination.

The product is RSV monoclonal antibody (mAb)

RSV monoclonal antibody (mAb) is a passive immunization product, not a vaccine, routinely recommended for seasonal prevention of RSV disease in infants. Record administration in an equivalent manner.

Before you go

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative and make sure they understand the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.

Sources

[1] Vaccine Administration Record for Children and Teens (5/31/2025), immunize.org (the Official source link on this page).

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.

Question	Answer
Form Name	Vaccination Record Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	467
Avg. time to fill out	1 min
Other names	immunization record card, children vaccine record, printable immunization card, vaccine record form printable