Vaccine Form – Fill Out and Use This PDF

The Vaccine Administration Record for Adults is an essential document designed to ensure the accurate tracking and administration of vaccines to adult patients. It stipulates the necessity of providing Vaccine Information Statements (VISs) to patients prior to vaccination, to ensure they are well-informed about the benefits and risks associated with the vaccines they receive. Furthermore, it details the procedure for recording crucial vaccine administration information, including the patient's name, birthdate, the vaccine given, and the administration route. To ensure you're properly documented for vaccine administration, click the button below to fill out the form.

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Vaccine Form PDF Details

The Vaccine Administration Record for Adults is a comprehensive tool designed to document all vaccines administered to an adult patient, ensuring that both healthcare providers and patients have a consistent and detailed record of immunizations. It carefully outlines the type of vaccine, the date it was given, the source of funding, the route of administration, and the specific site on the patient’s body where the vaccine was administered. Additionally, it mandates the provision of pertinent Vaccine Information Statements (VISs) to the patient prior to vaccination, emphasizing the importance of informed consent by ensuring that the patient understands the risks and benefits associated with each vaccine. This record not only facilitates the tracking and scheduling of future vaccinations but also serves as a critical piece of medical documentation that complies with federal requirements. It includes a section for the healthcare setting to maintain a reference list of vaccinators which is necessary due to space constraints and federal documentation standards. Moreover, the form lists not just contemporary vaccines but also those such as certain HPV vaccines, which are no longer available in the U.S. but may be relevant for historical patient records. This form thereby acts as both a clinical tool for healthcare providers and a vital piece of health documentation for patients, underscoring the multifaceted approach taken towards vaccination record-keeping.

Question	Answer
Form Name	Vaccine Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	vaccine record card, refusal to vaccinate form pdf, vaccine administration record form, vaccination record forms

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Vaccine Administration Record for Adults

Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits 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

		Date vaccine	Funding	Route3	Vaccine		Vaccine Information		Vaccinator5
Vaccine	Type of	Date vaccine	Funding	Route3	Vaccine		Statement (VIS)		Vaccinator5
	Type of	(mo/day/yr)	(F,S,P)2	Site3	Lot #	Mfr.	Statement (VIS)		initials and title)
	Vaccine1	(mo/day/yr)	(F,S,P)2	Site3	Lot #	Mfr.	Date on VIS4	Date given4	initials and title)
		given	Source	and					(signature or

Tetanus,
Diphtheria, Pertussis
Diphtheria, Pertussis
(e.g., Tdap, Td)
(e.g., Tdap, Td)
Give IM.3
Give IM.3


Hepatitis A
(e.g., HepA, HepA-HepB6)
(e.g., HepA, HepA-HepB6)
Give IM.3
Give IM.3

Hepatitis B1
(e.g., Engerix-B, Recombi-
(e.g., Engerix-B, Recombi-
vax HB, Heplisav-B, HepA-HepB6)
Give IM.3

Human papillomavirus
(HPV2, HPV4, HPV9)
Give IM.3
Give IM.3

Measles, Mumps, Rubella
(MMR) Give Subcut.3

Varicella (chickenpox,VAR)
Give Subcut.3
Give Subcut.3

Meningococcal ACWY
(e.g., MenACWY, MPSV4*)
(e.g., MenACWY, MPSV4*)
Give MenACWY IM.3

Meningococcal B
(e.g., MenB)
(e.g., MenB)
Give MenB IM.3
Give MenB IM.3

*HPV2, HPV4, and MPSV4 vaccines are no longer available in the U.S., but should be included in patient records for historical purposes.

•See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).

How to Complete this Record

1.With the exception of hepatitis B vaccines, record the generic abbrevia- tion (e.g., Tdap) or the trade name for each vaccine; for hepatitis B vac- cines, record the trade name (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 route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut [SC]), intradermal (ID), intranasal (NAS), or oral (PO) and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).

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, fill in a row for each antigen in the combination.

Abbreviation	Trade Name and Manufacturer

Tdap	Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td	Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
HepA	Havrix (GSK); Vaqta (Merck)
For hepatitis B,	Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax)
see footnote #1.

HepA-HepB	Twinrix (GSK)

HPV2*	Cervarix (GSK)
HPV4*, HPV9	Gardasil, Gardasil 9 (Merck)
MMR	MMRII (Merck)
VAR	Varivax (Merck)
MenACWY	Menactra (Sanofi Pasteur); Menveo (GSK)
MPSV4*	Menomune (Sanofi Pasteur)
MenB	Bexsero (GSK); Trumenba (Pfizer)

continued on the next page ▶

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

www.immunize.org/catg.d/p2023.pdf • Item #P2023 (8/18)

Vaccine Administration Record

for Adults (continued)

PAGE 2 0F 2

Patient name

Birthdate		Chart number

PRACTICE NAME AND ADDRESS

		Date vaccine	Funding	Route3	Vaccine		Vaccine Information		Vaccinator5
Vaccine	Type of	Date vaccine	Funding	Route3	Vaccine		Statement (VIS)		Vaccinator5
	Type of	given	Source	and			Statement (VIS)		(signature or
	Vaccine1	(mo/day/yr)	(F,S,P)2	Site3	Lot #	Mfr.	Date on VIS4	Date given4	initials and title)

Influenza
(e.g., IIV3, IIV4, ccIIV4,
(e.g., IIV3, IIV4, ccIIV4,
RIV3, RIV4, LAIV4)
RIV3, RIV4, LAIV4)
Give IIV3, IIV4, ccIIV3,
Give IIV3, IIV4, ccIIV3,
RIV3, and RIV4 IM.3
Give LAIV4 NAS.3










Pneumococcal conjugate
(e.g., PCV13) Give PCV13 IM.3

Pneumococcal polysac-
charide (e.g., PPSV23)
charide (e.g., PPSV23)
Give PPSV23 IM or
Subcut.3

Zoster (shingles)
Give RZV IM3
Give RZV IM3
Give ZVL Subcut3

Hib Give IM.3

Other

•See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB 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).

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.

Abbreviation	Trade Name and Manufacturer

IIV3/IIV4 (inactivated influenza vaccine,	Fluarix, FluLaval (GSK); Afluria, Fluad, Flu-
trivalent or quadrivalent); ccIIV4 (cell	celvax, Fluvirin (Seqirus); Flublok, Fluzone,
culture-based inactivated influenza	Fluzone Intradermal, Fluzone High-Dose
vaccine, quadrivalent); RIV3/RIV4	(Sanofi Pasteur)
(inactivated recombinant influenza
vaccine, trivalent or quadrivalent)

LAIV (live attenuated influenza	FluMist (MedImmune)
vaccine, quadrivalent]

PCV13	Prevnar 13 (Pfizer)
PPSV23	Pneumovax 23 (Merck)
RZV (recombinant zoster vaccine)	Shingrix, RZV (GSK);
ZVL (zoster vaccine, live)	Zostavax, ZVL (Merck)

Hib	ActHIB (Sanofi Pasteur); Hiberix (GSK);
	PedvaxHib (Merck)

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

www.immunize.org/catg.d/p2023.pdf • Item #P2023 – page 2 (8/18)

Vaccine Administration Record for Adults

PAGE 1 0F 2

Patient name Mike Schultz

Birthdate 5/31/1967		Chart number 010406

PRACTICE NAME AND ADDRESS

Small Rural Clinic

135 County Road 42

Smallville, IN 46902

			Date vaccine	Funding	Route3	Vaccine		Vaccine Information		Vaccinator5
Vaccine		Type of	Date vaccine	Funding	Route3	Vaccine		Statement (VIS)		Vaccinator5
		Type of	given	Source	and			Statement (VIS)		(signature or
		Vaccine1	given	Source	and					(signature or
		Vaccine1	(mo/day/yr)	(F,S,P)2	Site3	Lot #	Mfr.	Date on VIS4	Date given4	initials and title)

Tetanus,		Td	8/1/02	P	IM/LA	U0376AA	AVP	6/10/94	8/1/02	JTA
Diphtheria, Pertussis
Diphtheria, Pertussis		Td	9/1/02	P	IM/LA	U0376AA	AVP	6/10/94	9/1/02	RVO
(e.g., Tdap, Td)		Td	9/1/02	P	IM/LA	U0376AA	AVP	6/10/94	9/1/02	RVO

		Td	3/1/03	P	IM/LA	U0376AA	AVP	3/1/03	3/1/03	TAA
Give IM.3		Td	3/1/03	P	IM/LA	U0376AA	AVP	3/1/03	3/1/03	TAA

		Tdap	3/1/15	P	IM/LA	AC52B009AA	GSK	2/24/15	3/1/15	JTA
		Tdap	3/1/15	P	IM/LA	AC52B009AA	GSK	2/24/15	3/1/15	JTA


Hepatitis A
(e.g., HepA, HepA-HepB6)
(e.g., HepA, HepA-HepB6)
Give IM.3
Give IM.3

Hepatitis B1		Heplisav-B	2/5/18	P	IM/LA	TDG007	DVX	7/20/16	2/5/18	TAA
(e.g., Engerix-B, Recombi-
(e.g., Engerix-B, Recombi-	)	Heplisav-B	3/12/18	P	IM/LA	TDG007	DVX	7/20/16	3/12/18	TAA
6		Heplisav-B	3/12/18	P	IM/LA	TDG007	DVX	7/20/16	3/12/18	TAA
vax HB, Heplisav-B, HepA-HepB
Give IM.3

Human papillomavirus
(HPV2, HPV4, HPV9)
Give IM.3
Give IM.3

Measles, Mumps, Rubella		MMR	8/1/02	P	SC/RA	0025L	MSD	6/13/02	8/1/02	JTA
(MMR) Give Subcut.3
(MMR) Give Subcut.3		MMR	11/1/02	P	SC/RA	0025L	MSD	6/13/02	11/1/02	TAA
		MMR	11/1/02	P	SC/RA	0025L	MSD	6/13/02	11/1/02	TAA

Varicella (chickenpox,VAR)		VAR	8/1/02	P	SC/LA	0799M	MSD	12/16/98	8/1/02	JTA
Give Subcut.3
Give Subcut.3		VAR	11/1/02	P	SC/LA	0799M	MSD	12/16/98	11/1/02	TAA
		VAR	11/1/02	P	SC/LA	0799M	MSD	12/16/98	11/1/02	TAA

Meningococcal ACWY		MenACWY	7/12/11	P	IM/RA	M28011	NOV	3/2/08	7/12/11	RVO
(e.g., MenACWY, MPSV4*)
(e.g., MenACWY, MPSV4*)		Menveo	7/15/16	P	IM/LA	M12115	NOV	3/31/16	7/15/16	RVO
Give MenACWY IM.3		Menveo	7/15/16	P	IM/LA	M12115	NOV	3/31/16	7/15/16	RVO

Meningococcal B		MenB	1/14/16	P	IM/LA	J296203	PFR	8/14/15	1/14/16	RVO
(e.g., MenB)
(e.g., MenB)		Trumenba	9/15/16	P	IM/LA	J296203	PFR	8/14/15	9/15/16	RVO
Give MenB IM.3		Trumenba	9/15/16	P	IM/LA	J296203	PFR	8/14/15	9/15/16	RVO

*HPV2, HPV4, and MPSV4 vaccines are no longer available in the U.S., but should be included in patient records for historical purposes.

•See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines (e.g., travel vaccines).

How to Complete this Record

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

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, fill in a row for each antigen in the combination.

Abbreviation	Trade Name and Manufacturer

Tdap	Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Td	Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
HepA	Havrix (GSK); Vaqta (Merck)
For hepatitis B,	Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax)
see footnote #1.

HepA-HepB	Twinrix (GSK)

HPV2*	Cervarix (GSK)
HPV4*, HPV9	Gardasil, Gardasil 9 (Merck)
MMR	MMRII (Merck)
VAR	Varivax (Merck)
MenACWY	Menactra (Sanofi Pasteur); Menveo (GSK)

MPSV4*	Menomune (Sanofi Pasteur)
MenB	Bexsero (GSK); Trumenba (Pfizer)

continued on the next page ▶

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

www.immunize.org/catg.d/p2023.pdf • Item #P2023 (8/18)

Vaccine Administration Record

for Adults (continued)

PAGE 2 0F 2

Patient name Mike Schultz

Birthdate 5/31/1967		Chart number 010406

PRACTICE NAME AND ADDRESS

Small Rural Clinic

135 County Road 42

Smallville, IN 46902

		Date vaccine	Funding	Route3	Vaccine		Vaccine Information		Vaccinator5
Vaccine	Type of	Date vaccine	Funding	Route3	Vaccine		Statement (VIS)		Vaccinator5
	Type of	given	Source	and			Statement (VIS)		(signature or
	Vaccine1	(mo/day/yr)	(F,S,P)2	Site3	Lot #	Mfr.	Date on VIS4	Date given4	initials and title)

Influenza	Flulaval	10/2/09	P	IM/RA	2F600411	GSK	8/11/09	10/2/09	PWS
(e.g., IIV3, IIV4, ccIIV4,
(e.g., IIV3, IIV4, ccIIV4,	H1N1	12/7/09	P	IM/RA	10092224P	NOV	10/2/09	12/7/09	DLW
RIV3, RIV4, LAIV4)	H1N1	12/7/09	P	IM/RA	10092224P	NOV	10/2/09	12/7/09	DLW

	Afluria	9/12/10	P	IM/RA	06949111A	NOV	8/10/10	9/12/10	TAA
Give IIV3, IIV4, ccIIV3,	Afluria	9/12/10	P	IM/RA	06949111A	NOV	8/10/10	9/12/10	TAA

	Flulaval	10/1/11	P	IM/LA	2F750345	GSK	8/10/11	10/1/11	JTA
RIV3, and RIV4 IM.3	Flulaval	10/1/11	P	IM/LA	2F750345	GSK	8/10/11	10/1/11	JTA
Give LAIV4 NAS.3	IIV3	9/5/12	P	IM/RA	M50907	CSL	7/2/12	9/5/12	KKC
Give LAIV4 NAS.3
	RIV3	12/2/13	P	IM/RA	350603F	PSC	7/26/13	12/2/13	DCP

	IIV4	10/5/14	P	IM/RA	UI196AA	PMC	8/19/14	10/5/14	JTA

	IIV4	11/2/15	P	IM/LA	123773P	NOV	8/7/15	11/2/15	DCP

	IIV4	10/1/16	P	IM/LA	U1206AA	PMC	8/7/15	10/1/16	TAA

	ccIIV4	9/30/17	P	IM/LA	185128	SEQ	8/7/15	9/30/17	RVO






Pneumococcal conjugate	PCV13	11/1/12	P	IM/RA	7-5096-06A	WYE	4/16/10	11/1/12	CJP
(e.g., PCV13) Give PCV13 IM.3	PCV13	11/1/12	P	IM/RA	7-5096-06A	WYE	4/16/10	11/1/12	CJP

Pneumococcal polysac-	PPSV23	9/12/10	P	IM/RA	663012/1163X	MSD	10/6/09	9/12/10	TAA
charide (e.g., PPSV23)
charide (e.g., PPSV23)	PPSV23	11/2/15	P	IM/RA	663012/1163X	MSD	10/6/09	11/2/15	DCP
Give PPSV23 IM or	PPSV23	11/2/15	P	IM/RA	663012/1163X	MSD	10/6/09	11/2/15	DCP
Give PPSV23 IM or
Subcut.3

Zoster (shingles)	RZV	3/15/18	P	IM/RA	A1283	GSK	2/12/18	3/15/18	CJP
Give RZV IM3
Give RZV IM3	Shingrix	5/17/18	P	IM/RA	A1283	GSK	2/12/18	5/17/18	CJP
Give ZVL Subcut3	Shingrix	5/17/18	P	IM/RA	A1283	GSK	2/12/18	5/17/18	CJP

Hib Give IM.3	ActHIB	11/1/12	P	IM/RA	DO5561	PMC	4/16/10	11/1/12	CJP

Other

•See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, MenACWY, and MenB 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).

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.

Abbreviation	Trade Name and Manufacturer

IIV3/IIV4 (inactivated influenza vaccine,	Fluarix, FluLaval (GSK); Afluria, Fluad, Flu-
trivalent or quadrivalent); ccIIV4 (cell	celvax, Fluvirin (Seqirus); Flublok, Fluzone,
culture-based inactivated influenza	Fluzone Intradermal, Fluzone High-Dose
vaccine, quadrivalent); RIV3/RIV4	(Sanofi Pasteur)
(inactivated recombinant influenza
vaccine, trivalent or quadrivalent)

LAIV (live attenuated influenza	FluMist (MedImmune)
vaccine, quadrivalent]

PCV13	Prevnar 13 (Pfizer)
PPSV23	Pneumovax 23 (Merck)
RZV (recombinant zoster vaccine)	Shingrix, RZV (GSK);
ZVL (zoster vaccine, live)	Zostavax, ZVL (Merck)

Hib	ActHIB (Sanofi Pasteur); Hiberix (GSK);
	PedvaxHib (Merck)

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

www.immunize.org/catg.d/p2023.pdf • Item #P2023 – page 2 (8/18)

How to Edit Vaccine Form Online for Free

vaccine record card can be filled in online very easily. Just use FormsPal PDF editing tool to get it done promptly. Our development team is constantly working to improve the editor and enable it to be even easier for users with its many features. Make use of the latest progressive possibilities, and find a trove of new experiences! Here's what you'd want to do to get going:

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This PDF will require specific details to be filled out, so be certain to take your time to fill in what's required:

1. While completing the vaccine record card, make sure to incorporate all of the needed fields in their corresponding area. This will help to facilitate the process, which allows your information to be processed fast and correctly.

Step # 1 for completing immunization record

2. After completing the last part, go on to the next stage and complete the necessary details in all these blank fields - Hepatitis B eg EngerixB Recombi, Human papillomavirus HPV HPV HPV, Measles Mumps Rubella MMR Give, Varicella chickenpoxVAR Give Subcut, Meningococcal ACWY eg MenACWY MPSV, Meningococcal B eg MenB Give MenB, HPV HPV and MPSV vaccines are no, See page to record influenza, eg travel vaccines, How to Complete this Record With, Record the funding source of the, Abbreviation, Trade Name and Manufacturer, Tdap, and HepA.

Measles Mumps Rubella MMR Give, Hepatitis B eg EngerixB Recombi, and HepA in immunization record

3. Throughout this part, review Vaccine Administration Record for, Before administering any vaccines, page f, Patient name, Birthdate, practice name and address, Chart number, Type of Vaccine, Date vaccine, given, modayyr, Funding Source FSP, Route and Site, Vaccine, and Vaccine Information. All of these will need to be taken care of with utmost focus on detail.

Step # 3 in submitting immunization record

4. To go forward, this next stage will require typing in a few form blanks. Examples include Pneumococcal conjugate eg PCV Give, Pneumococcal polysac charide eg, Zoster shingles Give RZV IM Give, Hib Give IM, Other, See page to record TdapTd, MenACWY and MenB vaccines, How to Complete this Record, vaccine see table at right, Record the funding source of the, Abbreviation, Trade Name and Manufacturer, IIVIIV inactivated influenza, and Fluarix FluLaval GSK Afluria Fluad, which you'll find crucial to moving forward with this particular process.

Record the funding source of the, Fluarix FluLaval GSK Afluria Fluad, and How to Complete this Record of immunization record

People who use this form generally get some points incorrect while filling in Record the funding source of the in this area. You need to revise whatever you enter here.

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