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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)
