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P 1203
P 1203
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 patients personal record card.
Vaccine
Tetanus, Diphtheria, Pertussis (e.g., Td, Tdap) Give IM.6
Type of Vaccine1
Date given
(mo/day/yr)
Vaccine
Lot # Mfr.
Vaccinator5
(signature or initials & title)
Hepatitis A7 (e.g., HepA, HepA-HepB) Give IM.6 Hepatitis B7 (e.g., HepB, HepA-HepB) Give IM.6 Human papillomavirus (HPV2, HPV4) Give IM.6 Measles, Mumps, Rubella (MMR) Give SC.6 Varicella (VAR) Give SC.6
Pneumococcal polysaccharide (PPSV23) Give SC or IM. Meningococcal (e.g., MCV4, conjugate; MPSV4, polysaccharide) Give MCV4 IM. Give MPSV4 SC.
6 6 6
See page 2 to record influenza, zoster, and other vaccines (e.g., travel vaccines).
Abbreviation
Tdap Td HepA HepB HepA-HepB HPV2 HPV4 MMR VAR PPSV23 MCV4 MPSV4
Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
(Page 2 of 2)
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 patients personal record card.
Vaccine
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.6 Give LAIV IN.6
Type of Vaccine1
Date given
Vaccine
Lot # Mfr.
Vaccinator5
(signature or initials & title)
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal vaccines.
Abbreviation
LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) ZOS (shingles)
Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
(Page 1 of 2)
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 patients personal record card.
Vaccine
Tetanus, Diphtheria, Pertussis (e.g., Td, Tdap) Give IM.6
Type of Vaccine1
Date given
(mo/day/yr)
Vaccine
Lot # Mfr.
Vaccinator5
(signature or initials & title)
Hepatitis A7 (e.g., HepA, HepA-HepB) Give IM.6 Hepatitis B7 (e.g., HepB, HepA-HepB) Give IM.6 Human papillomavirus (HPV2, HPV4) Give IM.6 Measles, Mumps, Rubella (MMR) Give SC.6 Varicella (VAR) Give SC.6
8/01/02 9/1/2002 3/1/2003 6/14/2010 8/1/2002 9/1/2002 3/1/2003 8/1/2002 9/1/2002 3/1/2003
P P P P P P P P P P
LA LA LA LA RA RA RA RA RA RA
U0376AA U0376AA U0376AA AC52B030AA HAB239A4 HAB239A4 HAB239A4 HAB239A4 HAB239A4 HAB239A4
AVP AVP AVP GSK GSK GSK GSK GSK GSK GSK
6/10/94 6/10/94 6/10/94 11/18/2008 8/25/1998 8/25/1998 8/25/1998 7/11/2001 7/11/2001 7/11/2001
8/1/2002 9/1/2002 3/1/2003 6/14/2010 8/1/2002 9/1/2002 3/1/2003 8/1/2002 9/1/2002 3/1/2003
JTA PWS TAA JTA JTA PWS TAA JTA PWS TAA
1 shot, 2 different VIS dates MMR MMR VAR VAR Menveo 8/1/2002 11/1/2002 8/1/2002 11/1/2002 P P P P RA RA LA RA 0025L 0025L 0799M 0689M MRK MRK MRK MRK 6/13/2002 8/1/2002 6/13/2002 11/1/2002 12/16/1998 8/1/2002 12/16/1998 11/1/2002 JTA TAA JTA TAA JTA
7/12/2010
See page 2 to record influenza, zoster, and other vaccines (e.g., travel vaccines).
e l p m a Ex
P RA 28011 NOV 1/28/2008 7/12/2010
Abbreviation
Tdap Td HepA HepB HepA-HepB HPV2 HPV4 MMR VAR PPSV23 MCV4 MPSV4
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 IN (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. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. 7. For combination vaccines, fill in a row for each antigen in the combination.
This is a record for a 29-year-old healthcare worker who is planning to travel to Saudi Arabia for the annual Hajj.
Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
(Page 2 of 2)
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 patients personal record card.
Vaccine
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM.6 Give LAIV IN.6
Type of Vaccine1
Date given
Vaccine
Lot # Mfr.
Vaccinator5
(signature or initials & title)
TIV 11/1/2002 TIV 10/10/2003 Fluzone 10/8/2004 TIV 11/12/2005 Fluvirin 10/9/2006 Flumist 11/15/2007 Afluria 10/12/2008 Flulaval 10/2/2009 H1N1 12/7/2009
e l p m a Ex
P po TXE355 BER
Abbreviation
LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) ZOS (shingles) FluMist (MedImmune) Zostavax (Merck)
P P P P P P P P F
RA LA RA LA LA IN RA LA RA
5/19/2004 7/12/2010
MAT
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal vaccines.
This is a record for a 29-year-old healthcare worker who is planning to travel to Saudi Arabia for the annual Hajj.
Technical content reviewed by the Centers for Disease Control and Prevention, March 2011.
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org