FILE AS PAGE DIRECTLY BEHIND DD FORM 2766 ON LEFT SIDE OF MEDICAL RECORD
VACCINE ADMINISTRATION RECORD
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
This document complies with Article 80 of the World Health Organization International Health Regulations (IHR) of 1969.
International Health Regulations call for this document to be accepted in lieu of the International Certificate of Vaccination (PHS
Form 731) when traveling outside the United States. In accordance with the IHR, this automated record is an equivalent
document issued by the United States Armed Forces.
By inserting the Vaccine Information Statement (VIS) version date in the applicable field, providers verify that the vaccine(s)
annotated were administered and current VISs were given to the parent, legal guardian or patient. This form complies with
federal record-keeping requirements of the National Childhood Vaccine Injury Act of 1986 as amended 14 December 1993.
Parent, guardian, or patient signature is not required unless state law mandates a guardian signature and proof of informed
consent.
Vaccine (Series) Date Manufacturer Lot Number Dosage VIS Version Administering Tech
ANTHRAX 1/24/2008 Bioport UNK 0 5 CC P JOHNSON SRP
ANTHRAX 2/13/2008 Bioport UNK 0 5 ML WILLIAMS VICKIE
ANTHRAX 3/5/2008 Bioport UNK 0 5 ML FAESTEL PAUL
ANTHRAX 12/20/2008 Bioport FAV148 0.5 CC
HEP A, ADULT 11/7/1999 Unknown UNK 1.0 CC
HEP A, ADULT 6/4/2000 Unknown UNK 1.0 CC
HEP A, ADULT 10/23/2015 GlaxoSmithkline 7K5T4 1.0 CC SGT DEMASS
HEP B, ADULT 7/13/2005 Unknown ENG5444A4 1ML DUFFY CHRISTIAN
HEP B, ADULT 10/9/2005 Merck 0864B 1.0 CC SPC TORUNO
HEP B, ADULT 9/9/2007 GlaxoSmithkline AHBVB443AA 1.0 CC SPC DONOVAN
INFLUENZA SEAS
PRESERVATIVE 12/4/2011 Unknown 14649121A 0.5CC SFC JORGENSON
FREE
INFLUENZA SEAS
PRESERVATIVE 10/11/2012 CSL Biotherapies P58907 0.5CC SSG JAMESON
FREE
INFLUENZA SEAS
PRESERVATIVE 10/14/2012 CSL Biotherapies P58907 0.5CC CARPENTER
FREE
INFLUENZA SEAS
PRESERVATIVE 11/13/2013 Novartis 13414P 0.5CC UNK
FREE
INFLUENZA SEAS
PRESERVATIVE 10/25/2014 Novartis 160234 0.5 CC UNK
FREE
Address: Name: Sex:
14149 MILL CANYON PEAK DR CARLILE KRISTOPHER JASON M
RIVERTON, UT 840960000 Status: Rank:
Army National Guard CPT
Service: Sponsor's SSN: DOB:
Army 543-88-4015 5-Aug-1974
DD FORM 2766C (Computer Generated) - MEDPROS Generated 25 Sep 2016 11:55
1 of 3
FILE AS PAGE DIRECTLY BEHIND DD FORM 2766 ON LEFT SIDE OF MEDICAL RECORD
VACCINE ADMINISTRATION RECORD
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
This document complies with Article 80 of the World Health Organization International Health Regulations (IHR) of 1969.
International Health Regulations call for this document to be accepted in lieu of the International Certificate of Vaccination (PHS
Form 731) when traveling outside the United States. In accordance with the IHR, this automated record is an equivalent
document issued by the United States Armed Forces.
By inserting the Vaccine Information Statement (VIS) version date in the applicable field, providers verify that the vaccine(s)
annotated were administered and current VISs were given to the parent, legal guardian or patient. This form complies with
federal record-keeping requirements of the National Childhood Vaccine Injury Act of 1986 as amended 14 December 1993.
Parent, guardian, or patient signature is not required unless state law mandates a guardian signature and proof of informed
consent.
Vaccine (Series) Date Manufacturer Lot Number Dosage VIS Version Administering Tech
INFLUENZA SEAS
PRESERVATIVE 10/23/2015 Novartis 1517301 0.5CC SGT DEMASS
FREE
INFLUENZA SPLIT 1/20/2001 Wyeth-Ayerst 4008222 0.5 CC
INFLUENZA SPLIT 1/4/2002 Aventis U0683EB 0.5 CC
INFLUENZA SPLIT 12/15/2002 Unknown UNK 0.5 CC
INFLUENZA SPLIT 6/21/2005 Aventis U1528AA 0.5 CC UNK
INFLUENZA SPLIT 12/2/2006 Aventis U2310AA 0.5 CC UNK
INFLUENZA SPLIT 1/12/2008 GlaxoSmithkline AFLUA316BA 0.5 CC ONUSKA
INFLUENZA SPLIT 12/20/2008 Unknown UNK 0.5 CC
INFLUENZA SPLIT 11/6/2010 CSL Biotherapies M53309 0.5 CC SSG KERBO
MENINGOCOCCAL 8/3/1998 Unknown UNK 0.5 CC
MMR 6/30/1993 Unknown UNK 0.5 CC UNK
MMR 8/3/1998 Unknown UNK 0.5 CC
MMR 12/1/1999 Unknown UNK 0.5 CC UNK
POLIO, OPV 8/3/1998 Unknown UNK 2 GGTS
SMALLPOX (Read:
MAJOR Date: 31 Jan 1/24/2008 Wyeth-Ayerst 4020076 3 JSTILES SSRP
08)
TETANUS AND
DIPHTHERIA, 8/3/1998 Unknown UNK 0.5 CC
ADULT
TETANUS-
DIPHTHERIA- 12/20/2008 Unknown UNK 0.5 CC
PERTUSSIS
Address: Name: Sex:
14149 MILL CANYON PEAK DR CARLILE KRISTOPHER JASON M
RIVERTON, UT 840960000 Status: Rank:
Army National Guard CPT
Service: Sponsor's SSN: DOB:
Army 543-88-4015 5-Aug-1974
DD FORM 2766C (Computer Generated) - MEDPROS Generated 25 Sep 2016 11:55
2 of 3
FILE AS PAGE DIRECTLY BEHIND DD FORM 2766 ON LEFT SIDE OF MEDICAL RECORD
VACCINE ADMINISTRATION RECORD
(THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974)
This document complies with Article 80 of the World Health Organization International Health Regulations (IHR) of 1969.
International Health Regulations call for this document to be accepted in lieu of the International Certificate of Vaccination (PHS
Form 731) when traveling outside the United States. In accordance with the IHR, this automated record is an equivalent
document issued by the United States Armed Forces.
By inserting the Vaccine Information Statement (VIS) version date in the applicable field, providers verify that the vaccine(s)
annotated were administered and current VISs were given to the parent, legal guardian or patient. This form complies with
federal record-keeping requirements of the National Childhood Vaccine Injury Act of 1986 as amended 14 December 1993.
Parent, guardian, or patient signature is not required unless state law mandates a guardian signature and proof of informed
consent.
Vaccine (Series) Date Manufacturer Lot Number Dosage VIS Version Administering Tech
TUBERCULIN SKIN
6/21/2005 Aventis C2079AA 0.1ML UNK
TEST, PPD
TUBERCULIN SKIN
1/26/2008 Aventis 43677 0 1 ML SRP DSAUNDERS
TEST, PPD
TYPHOID,
PARENTERAL, 6/4/2000 Unknown UNK 0.5 CC
NON-AKD
TYPHOID, ViCPs 1/24/2008 Aventis Z09222 0 5 CC P JOHNSON SRP
YELLOW FEVER 1/20/2001 Other UA228AA 0.5 CC
Immunization Exemptions
Vaccine Exemption Expiration Date
VARICELLA Medical Assumed Indefinite
LAST ITEM
DO NOT MAKE ENTRIES BELOW THIS BLOCK
Address: Name: Sex:
14149 MILL CANYON PEAK DR CARLILE KRISTOPHER JASON M
RIVERTON, UT 840960000 Status: Rank:
Army National Guard CPT
Service: Sponsor's SSN: DOB:
Army 543-88-4015 5-Aug-1974
DD FORM 2766C (Computer Generated) - MEDPROS Generated 25 Sep 2016 11:55
3 of 3
