page 1 0f 2

Vaccine Administration Record Patient name

Birthdate Chart number
for Children and Teens practice name and address
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 benefits of the vaccine(s).
Always provide or update the patient’s personal record card.

Date vaccine Funding Vaccine Vaccine Information Vaccinator5

Type of Statement (VIS)
Vaccine Vaccine1
given Source Site3 (signature or
(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 influenzae
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, influenza, and other vaccines (e.g., travel vaccines). Abbreviation Trade Name and Manufacturer
Daptacel (Sanofi Pasteur); Infanrix (GlaxoSmithKline [GSK]);
DTaP
How to Complete this Record Tripedia (Sanofi Pasteur)
DT (pediatric) Generic (Sanofi Pasteur)
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each DTaP-HepB-IPV Pediarix (GSK)
vaccine (see table at right). DTaP-IPV/Hib Pentacel (Sanofi Pasteur)
2. Record the funding source of the vaccine given as either F (federal), DTaP-IPV Kinrix (GSK); Quadracel (Sanofi Pasteur)
S (state), or P (private). HepB Engerix-B (GSK); Recombivax HB (Merck)
3. Record the site where vaccine was administered as either RA (right arm), HepA-HepB Twinrix (GSK); can be given to teens age 18 and older
Hib ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHIB (Merck)
LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal).
Hib-MenCY MenHibrix (GSK)
4. Record the publication date of each VIS as well as the date the VIS is IPV Ipol (Sanofi Pasteur)
given to the patient. PCV13 Prevnar 13 (Pfizer)
5. To meet the space constraints of this form and federal requirements for PPSV23 Pneumovax 23 (Merck)
documentation, a healthcare setting may want to keep a reference list of RV1 Rotarix (GSK)
vaccinators that includes their initials and titles. RV5 RotaTeq (Merck)
6. For combination vaccines, fill in a row for each antigen in the combination. Tdap Adacel (Sanofi Pasteur); Boostrix (GSK)
7. IM is the abbreviation for intramuscular; Subcut is the abbreviation for Td Decavac, Tenivac (Sanofi Pasteur); Generic (MA Biological Labs)

subcutaneous.

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)
 page 2 0f 2
Vaccine Administration Record Patient name
for Children and Teens (continued) Birthdate Chart number

practice name and address

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

Date vaccine Funding Vaccine Vaccine Information Vaccinator5

Type of Statement (VIS)
Vaccine Vaccine1
given Source Site3 (signature or
(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

Influenza (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 Abbreviation Trade Name and Manufacturer
influenzae type b, polio, pneumococcal, and rotavirus vaccines.
MMR MMRII (Merck)
How to Complete this Record VAR Varivax (Merck)
MMRV ProQuad (Merck)
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each HepA Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck)
vaccine (see table at right). HepA-HepB Twinrix (GSK)
2. Record the funding source of the vaccine given as either F (federal), HPV2 Cervarix (GSK)
S (state), or P (private). HPV4, HPV9 Gardasil, Gardasil 9 (Merck)
3. Record the site where vaccine was administered as either RA (right arm), LAIV4 (live attenuated influ- FluMist (MedImmune)
LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal). enza vaccine, quadrivalent)

4. Record the publication date of each VIS as well as the date the VIS is IIV3 (inactivated influenza vac-
cine, trivalent), IIV4 (inactivated
given to the patient. influenza vaccine, quadrivalent), Fluarix (GSK); Flublok (Protein Sciences Corp.);
ccIIV3 (cell culture-based Afluria, Fluad, Flucelvax, Fluvirin (Seqirus);
5. To meet the space constraints of this form and federal requirements for inactivated influenza vaccine, FluLaval (GSK); Fluzone (Sanofi Pasteur)
trivalent), RIV3 (inactivated
documentation, a healthcare setting may want to keep a reference list of recombinant influenza vaccine,
vaccinators that includes their initials and titles. trivalent)

6. For combination vaccines, fill in a row for each antigen in the combination. MenACWY Menactra (Sanofi Pasteur); Menveo (GSK)
7. IM is the abbreviation for intramuscular; Subcut is the abbreviation for HibMenCY MenHibrix (GSK)
MenB Bexsero (GSK); Trumenba (Pfizer)
subcutaneous.

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)
 page 1 0f 2
Samantha Jo Swenson
Vaccine Administration Record 3DWLHQWQDPH
6/1/2010
for Children and Teens
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given Source Site3 VLJQDWXUHRU
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Diphtheria, Tetanus, Pediarix 8/2/2010 F IM/RT 635A1 GSK 5/17/07 8/2/2010 DCP
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type b6 Hib 10/2/2010 F IM/RT 1492L MSD 12/16/98 10/2/2010 DCP
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F 712A2 1/1/00 10/2/2010
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Rotavirus 5959 RV5 8/2/2010 F PO 05849 MSD 5/14/10 8/2/2010 DCP

*LYHRUDOO\ SR  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

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 page 2 0f 2
Samantha Jo Swenson
Vaccine Administration Record 3DWLHQWQDPH
6/1/2010
for Children and Teens FRQWLQXHG %LUWKGDWH&KDUWQXPEHU

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Date vaccine Funding Vaccine Vaccine Information Vaccinator5

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Vaccine Vaccine1
given Source Site3 VLJQDWXUHRU
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