Vaccination Records - Children And Teens
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Vaccination Records - Children And Teens as PDF for free.
More details
- Words: 1,957
- Pages: 4
Vaccine Administration Record for Children and Teens
Patient name:
Type of Vaccine1
Vaccine
Vaccine
(generic abbreviation)
Date given Source (mo/day/yr) (F,S,P) 2
Site3
Birthdate: Chart number:
Lot #
Vaccine Information Statement Mfr.
Date on VIS4
Date given4
Signature/ initials of vaccinator
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
Diphtheria, Tetanus, Pertussis5 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-IPV, Td) Give IM.
Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM. Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM. Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. Varicella5 (e.g., Var, MMRV) Give SC. Hepatitis A (HepA) Give IM. Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC. Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN. Other 1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds). Technical content reviewed by the Centers for Disease Control and Prevention, February 2008.
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination. www.immunize.org/catg.d/p2022.pdf • Item #P2022 (2/08)
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record for Children and Teens Type of Vaccine1
Vaccine
(generic abbreviation)
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
Diphtheria, Tetanus, Pertussis5 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-IPV, Td) Give IM.
Hib-HepB (Comvax) Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM. Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM. Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. MMRV
HepB Hib-HepB Hib-HepB Hib-Hep B DTaP DTaP DTaP DTaP
Date given Source (mo/day/yr) (F,S,P)2
Site3
2/03/06 4/03/06 6/05/06 2/05/07 4/03/06 6/05/06 8/07/06 5/07/07
RT RT RT LT RT RT RT RT
S S S S S S S S
Patient name: Birthdate:
Shawn Abler February 3, 2006
Chart number: SA-4837 Vaccine Information Statement
Vaccine Lot #
Mfr.
0651M 1051M 1051M 1106M 647A2 647A2 647A2 749B1
MRK MRK MRK MRK GSK GSK GSK GSK
Date on VIS4
Date given4
7/11/01 7/11/01 7/11/01 7/11/01 7/30/01 7/30/01 7/30/01 7/30/01
2/03/06 4/03/06 6/05/06 2/05/07 4/03/06 6/05/06 8/07/06 5/07/07
Signature/ initials of vaccinator
JTA DCP DCP DCP DCP DCP DCP DCP
1 shot, 2 different VIS dates
1 # e l p m a x E Hib-HepB Hib-HepB Hib-HepB
4/03/06 6/05/06 2/05/07
S S S
RT RT LT
1051M 1051M 1106M
MRK MRK MRK
12/16/98 12/16/98 12/16/98
4/03/06 6/05/06 2/05/07
DCP DCP DCP
IPV IPV IPV
4/03/06 6/05/06 4/03/07
S S S
LT LT LT
U4569-8 U4569-8 U4569-8
SPI SPI SPI
1/01/00 1/01/00 1/01/00
4/03/06 6/05/06 4/03/07
DCP DCP DCP
PCV PCV PCV PCV Rota Rota Rota MMRV
4/03/06 6/05/06 8/07/06 2/05/07 4/03/06 6/05/06 8/07/06 2/05/07
S S S S P P P P
LT RT LT RT po po po RT
489-835 489-835 489-835 591-123 1234F 1234F 1234F 0857M
WYE WYE WYE WYE MRK MRK MRK MRK
9/30/02 9/30/02 9/30/02 9/30/02
4/03/06 6/05/06 8/07/06 2/05/07
4/12/06 4/12/06 1/15/03
6/05/06 8/07/06 2/05/07
DCP DCP DCP DCP DCP DCP DCP DCP
1 shot, 2 different VIS dates
(ProQuad)
Varicella5 (e.g., Var, MMRV) Give SC.
MMRV
2/05/07
P
RT
0857M
MRK
1/10/07
2/05/07
DCP
Hepatitis A (HepA) Give IM.
HepA HepA
4/03/07 10/03/07
S S
RT RT
0634K 0634K
MRK MRK
3/21/06 3/21/06
4/03/07 10/03/07
DCP DCP
SPI SPI SPI
6/30/06 6/30/06 7/16/07
10/09/06 11/13/06 10/16/07
DCP DCP DCP
Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC.
How to rrecor ecor d Hib-HepB and ecord MMR V combination vvaccines accines MMRV
Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN.
TIV TIV TIV
10/09/06 11/13/06 10/16/07
P P P
RT RT RT
U106459 U106459 U463152
Other 1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds).
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record for Children and Teens
Patient name:
Type of Vaccine1
Vaccine
Vaccine
(generic abbreviation)
Date given Source (mo/day/yr) (F,S,P)2
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
HepB 12/02/04 DTaP-HepB-IPV 2/02/05 DTaP-HepB-IPV 4/02/05 DTaP-HepB-IPV (Pediarix) DTaP-HepB-IPV 6/02/05 DTaP-HepB-IPV 2/02/05 Diphtheria, Tetanus, Pertussis DTaP-HepB-IPV 4/02/05 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV 6/02/05 DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-Hib 3/02/06 DTaP-IPV, Td) 5
F F F F F F F F
Give IM.
Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. Varicella5 (e.g., Var, MMRV) Give SC. Hepatitis A (HepA) Give IM.
Chart number:
Lot #
RT RT RT RT RT RT RT RA
0651M 635A2 712A2 712A2 635A2 712A2 712A2 PO897AA
Vaccine Information Statement Mfr.
MRK GSK GSK GSK GSK GSK GSK SPI
Date on VIS4
7/11/01 7/11/01 7/11/01 7/11/01 7/30/01 7/30/01 7/30/01 7/30/01
Date given4
12/02/04 2/02/05 4/02/05 06/02/05 2/02/05 4/02/05 6/02/05 3/02/06
Signature/ initials of vaccinator
JTA DCP DCP DLW DCP DCP DLW RLV
1 shot, 3 different VIS dates
Hib Hib Hib DTaP-Hib DTaP-HepB-IPV DTaP-HepB-IPV DTaP-HepB-IPV
2/02/05 4/02/05 6/02/05 3/02/06 2/02/05 4/02/05 6/02/05
F F F F F F F
LT LT LT RA RT RT RT
UA744AA UA744AA UA744AA 7172AA 635A2 712A2 712A2
SPI SPI SPI SPI GSK GSK GSK
12/16/98 12/16/98 12/16/98 12/16/98 1/01/00 1/01/00 1/01/00
2/02/05 4/02/05 6/02/05 3/02/05 2/02/05 4/02/05 6/02/05
DCP DCP DLW RLV DCP DCP DLW
PCV PCV PCV PCV
2/02/05 4/02/05 6/02/05 3/02/06
F F F F
LT RT LT LA
489-835 489-835 489-835 501-245
WYE WYE WYE WYE
9/30/02 9/30/02 9/30/02 9/30/02
2/02/05 4/02/05 6/02/05 3/02/06
DCP DCP DLW RLV
2 # e l p m a x E
Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM.
Birthdate:
1 shot, 2 lot #s
DTaP-Hib (Trihibit) Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM.
Site3
Renee Schmidt December 2, 2004 2345678
How to rrecor ecor d DT aP-HepB-IPV and ecord DTaP-HepB-IPV DT aP-Hib combination vvaccines accines DTaP-Hib
MMRV
12/02/05
P
RA
0857M
MRK
1/15/03
12/02/05
DLW
MMRV
12/02/05
P
LA
0857M
MRK 12/16/98
12/02/05
DLW
HepA HepA
12/02/05 6/02/06
F F
LA LA
0524L 0634K
MRK 8/04/04 MRK 3/21/06
12/02/05 6/02/06
MAT MAT
TIV TIV TIV
10/05/05 11/05/05 10/16/06
F F F
RA RA LA
U097543 U097543 U106459
SPI SPI SPI
10/05/05 11/05/05 10/16/06
JTA DCP MAT
Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC. Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN.
7/18/06 10/20/05 6/30/06
Other 1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds).
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record for Children and Teens
Patient name:
Type of Vaccine1
Vaccine
Vaccine
(generic abbreviation)
Date given Source (mo/day/yr) (F,S,P)2
Site3
6/02/02 1/02/03
P P
Jane Stamper October 15, 1989 3456789
Birthdate: Chart number:
Vaccine Information Statement
Signature/ initials of vaccinator
Lot #
Mfr.
RA RA
0651M 0651M
MRK MRK
7/11/01 7/11/01
6/02/02 1/02/03
TAA TAA
Date on VIS4
Date given4
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
HepB (1.0 ml) HepB (1.0 ml)
Diphtheria, Tetanus, Pertussis5 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-IPV, Td) Give IM.
DTP DTP DTP DTP DTP Td Hib Hib Hib
12/15/89 2/15/90 4/15/90 4/15/91 4/15/94 10/15/01 12/15/89 2/15/90 10/15/90
P P P P P P P P P
RT RT RT RA RA RA LT LT LT
326-912 326-912 326-912 326-912 326-912 467-854 1492L 1492L 1492L
LED LED LED LED LED WAL MRK MRK MRK
1/01/88 1/01/88 1/01/88 1/01/88 10/15/91 6/10/04 6/01/89 6/01/89 6/01/89
12/15/89 2/15/90 4/15/90 4/15/91 4/15/94 10/15/01 12/15/89 2/15/90 10/15/90
DCP DCP DLW RLV JTA PWS DCP DCP DLW
OPV OPV OPV OPV
12/15/89 2/15/90 4/15/91 4/15/94
P P P P
po po po po
0678A 0678A 0896A 0987A
LED LED LED LED
3/01/83 3/01/83 3/01/83 10/15/91
12/15/89 2/15/90 4/15/91 4/15/94
3 # e l p m a x E
DCP DCP RLV JTA
2-dose adult HepB for adolescents
Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM. Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM. Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. Varicella5 (e.g., Var, MMRV) Give SC. Hepatitis A (HepA) Give IM. Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC. Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN. Other
How to rrecor ecor d adult HepB ecord vaccine giv given en to 11-15 year olds
MMR MMR Var Var
1/15/91 10/15/01 10/15/01 10/15/07
P P P P
RA LA LA LA
0857M 0946M 0799M 0689M
MRK MRK MRK MRK
1/01/88 1/01/88 12/16/98 1/10/07
1/15/91 10/15/01 10/15/01 10/15/07
DLW PWS PWS JTA
MCV4
8/19/05
P
LA
U1766AA
SPI
4/4/05
8/19/05
DCP
HPV HPV HPV LAIV
9/12/06 11/14/06 3/14/07 10/15/07
P P P P
RA RA LA IN
0637F 0637F 0637F 500491P
MRK MRK MRK MED
9/6/06 9/5/06 2/02/07 10/04/07
9/12/06 11/14/06 3/14/07 10/15/07
MAT MAT JTA MAT
Tdap
7/9/06
P
LA
C2454AA
SPI
9/22/05
7/9/06
MAT
1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds).
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Patient name:
Type of Vaccine1
Vaccine
Vaccine
(generic abbreviation)
Date given Source (mo/day/yr) (F,S,P) 2
Site3
Birthdate: Chart number:
Lot #
Vaccine Information Statement Mfr.
Date on VIS4
Date given4
Signature/ initials of vaccinator
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
Diphtheria, Tetanus, Pertussis5 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-IPV, Td) Give IM.
Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM. Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM. Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. Varicella5 (e.g., Var, MMRV) Give SC. Hepatitis A (HepA) Give IM. Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC. Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN. Other 1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds). Technical content reviewed by the Centers for Disease Control and Prevention, February 2008.
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination. www.immunize.org/catg.d/p2022.pdf • Item #P2022 (2/08)
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record for Children and Teens Type of Vaccine1
Vaccine
(generic abbreviation)
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
Diphtheria, Tetanus, Pertussis5 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-IPV, Td) Give IM.
Hib-HepB (Comvax) Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM. Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM. Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. MMRV
HepB Hib-HepB Hib-HepB Hib-Hep B DTaP DTaP DTaP DTaP
Date given Source (mo/day/yr) (F,S,P)2
Site3
2/03/06 4/03/06 6/05/06 2/05/07 4/03/06 6/05/06 8/07/06 5/07/07
RT RT RT LT RT RT RT RT
S S S S S S S S
Patient name: Birthdate:
Shawn Abler February 3, 2006
Chart number: SA-4837 Vaccine Information Statement
Vaccine Lot #
Mfr.
0651M 1051M 1051M 1106M 647A2 647A2 647A2 749B1
MRK MRK MRK MRK GSK GSK GSK GSK
Date on VIS4
Date given4
7/11/01 7/11/01 7/11/01 7/11/01 7/30/01 7/30/01 7/30/01 7/30/01
2/03/06 4/03/06 6/05/06 2/05/07 4/03/06 6/05/06 8/07/06 5/07/07
Signature/ initials of vaccinator
JTA DCP DCP DCP DCP DCP DCP DCP
1 shot, 2 different VIS dates
1 # e l p m a x E Hib-HepB Hib-HepB Hib-HepB
4/03/06 6/05/06 2/05/07
S S S
RT RT LT
1051M 1051M 1106M
MRK MRK MRK
12/16/98 12/16/98 12/16/98
4/03/06 6/05/06 2/05/07
DCP DCP DCP
IPV IPV IPV
4/03/06 6/05/06 4/03/07
S S S
LT LT LT
U4569-8 U4569-8 U4569-8
SPI SPI SPI
1/01/00 1/01/00 1/01/00
4/03/06 6/05/06 4/03/07
DCP DCP DCP
PCV PCV PCV PCV Rota Rota Rota MMRV
4/03/06 6/05/06 8/07/06 2/05/07 4/03/06 6/05/06 8/07/06 2/05/07
S S S S P P P P
LT RT LT RT po po po RT
489-835 489-835 489-835 591-123 1234F 1234F 1234F 0857M
WYE WYE WYE WYE MRK MRK MRK MRK
9/30/02 9/30/02 9/30/02 9/30/02
4/03/06 6/05/06 8/07/06 2/05/07
4/12/06 4/12/06 1/15/03
6/05/06 8/07/06 2/05/07
DCP DCP DCP DCP DCP DCP DCP DCP
1 shot, 2 different VIS dates
(ProQuad)
Varicella5 (e.g., Var, MMRV) Give SC.
MMRV
2/05/07
P
RT
0857M
MRK
1/10/07
2/05/07
DCP
Hepatitis A (HepA) Give IM.
HepA HepA
4/03/07 10/03/07
S S
RT RT
0634K 0634K
MRK MRK
3/21/06 3/21/06
4/03/07 10/03/07
DCP DCP
SPI SPI SPI
6/30/06 6/30/06 7/16/07
10/09/06 11/13/06 10/16/07
DCP DCP DCP
Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC.
How to rrecor ecor d Hib-HepB and ecord MMR V combination vvaccines accines MMRV
Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN.
TIV TIV TIV
10/09/06 11/13/06 10/16/07
P P P
RT RT RT
U106459 U106459 U463152
Other 1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds).
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record for Children and Teens
Patient name:
Type of Vaccine1
Vaccine
Vaccine
(generic abbreviation)
Date given Source (mo/day/yr) (F,S,P)2
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
HepB 12/02/04 DTaP-HepB-IPV 2/02/05 DTaP-HepB-IPV 4/02/05 DTaP-HepB-IPV (Pediarix) DTaP-HepB-IPV 6/02/05 DTaP-HepB-IPV 2/02/05 Diphtheria, Tetanus, Pertussis DTaP-HepB-IPV 4/02/05 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV 6/02/05 DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-Hib 3/02/06 DTaP-IPV, Td) 5
F F F F F F F F
Give IM.
Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. Varicella5 (e.g., Var, MMRV) Give SC. Hepatitis A (HepA) Give IM.
Chart number:
Lot #
RT RT RT RT RT RT RT RA
0651M 635A2 712A2 712A2 635A2 712A2 712A2 PO897AA
Vaccine Information Statement Mfr.
MRK GSK GSK GSK GSK GSK GSK SPI
Date on VIS4
7/11/01 7/11/01 7/11/01 7/11/01 7/30/01 7/30/01 7/30/01 7/30/01
Date given4
12/02/04 2/02/05 4/02/05 06/02/05 2/02/05 4/02/05 6/02/05 3/02/06
Signature/ initials of vaccinator
JTA DCP DCP DLW DCP DCP DLW RLV
1 shot, 3 different VIS dates
Hib Hib Hib DTaP-Hib DTaP-HepB-IPV DTaP-HepB-IPV DTaP-HepB-IPV
2/02/05 4/02/05 6/02/05 3/02/06 2/02/05 4/02/05 6/02/05
F F F F F F F
LT LT LT RA RT RT RT
UA744AA UA744AA UA744AA 7172AA 635A2 712A2 712A2
SPI SPI SPI SPI GSK GSK GSK
12/16/98 12/16/98 12/16/98 12/16/98 1/01/00 1/01/00 1/01/00
2/02/05 4/02/05 6/02/05 3/02/05 2/02/05 4/02/05 6/02/05
DCP DCP DLW RLV DCP DCP DLW
PCV PCV PCV PCV
2/02/05 4/02/05 6/02/05 3/02/06
F F F F
LT RT LT LA
489-835 489-835 489-835 501-245
WYE WYE WYE WYE
9/30/02 9/30/02 9/30/02 9/30/02
2/02/05 4/02/05 6/02/05 3/02/06
DCP DCP DLW RLV
2 # e l p m a x E
Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM.
Birthdate:
1 shot, 2 lot #s
DTaP-Hib (Trihibit) Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM.
Site3
Renee Schmidt December 2, 2004 2345678
How to rrecor ecor d DT aP-HepB-IPV and ecord DTaP-HepB-IPV DT aP-Hib combination vvaccines accines DTaP-Hib
MMRV
12/02/05
P
RA
0857M
MRK
1/15/03
12/02/05
DLW
MMRV
12/02/05
P
LA
0857M
MRK 12/16/98
12/02/05
DLW
HepA HepA
12/02/05 6/02/06
F F
LA LA
0524L 0634K
MRK 8/04/04 MRK 3/21/06
12/02/05 6/02/06
MAT MAT
TIV TIV TIV
10/05/05 11/05/05 10/16/06
F F F
RA RA LA
U097543 U097543 U106459
SPI SPI SPI
10/05/05 11/05/05 10/16/06
JTA DCP MAT
Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC. Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN.
7/18/06 10/20/05 6/30/06
Other 1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds).
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Vaccine Administration Record for Children and Teens
Patient name:
Type of Vaccine1
Vaccine
Vaccine
(generic abbreviation)
Date given Source (mo/day/yr) (F,S,P)2
Site3
6/02/02 1/02/03
P P
Jane Stamper October 15, 1989 3456789
Birthdate: Chart number:
Vaccine Information Statement
Signature/ initials of vaccinator
Lot #
Mfr.
RA RA
0651M 0651M
MRK MRK
7/11/01 7/11/01
6/02/02 1/02/03
TAA TAA
Date on VIS4
Date given4
Hepatitis B5 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.
HepB (1.0 ml) HepB (1.0 ml)
Diphtheria, Tetanus, Pertussis5 (e.g., DTaP, DTaP-Hib, DTaP-HepB-IPV, DT, DTaP-Hib-IPV, Tdap, DTaP-IPV, Td) Give IM.
DTP DTP DTP DTP DTP Td Hib Hib Hib
12/15/89 2/15/90 4/15/90 4/15/91 4/15/94 10/15/01 12/15/89 2/15/90 10/15/90
P P P P P P P P P
RT RT RT RA RA RA LT LT LT
326-912 326-912 326-912 326-912 326-912 467-854 1492L 1492L 1492L
LED LED LED LED LED WAL MRK MRK MRK
1/01/88 1/01/88 1/01/88 1/01/88 10/15/91 6/10/04 6/01/89 6/01/89 6/01/89
12/15/89 2/15/90 4/15/90 4/15/91 4/15/94 10/15/01 12/15/89 2/15/90 10/15/90
DCP DCP DLW RLV JTA PWS DCP DCP DLW
OPV OPV OPV OPV
12/15/89 2/15/90 4/15/91 4/15/94
P P P P
po po po po
0678A 0678A 0896A 0987A
LED LED LED LED
3/01/83 3/01/83 3/01/83 10/15/91
12/15/89 2/15/90 4/15/91 4/15/94
3 # e l p m a x E
DCP DCP RLV JTA
2-dose adult HepB for adolescents
Haemophilus influenzae type b5 (e.g., Hib, Hib-HepB, DTaP-Hib-IPV, DTaP-Hib) Give IM. Polio5 (e.g., IPV, DTaP-HepB-IPV, DTaP-Hib-IPV, DTaP-IPV) Give IPV SC or IM. Give all others IM. Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) Give PCV IM. Give PPV SC or IM. Rotavirus (Rota) Give oral (po).
Measles, Mumps, Rubella5 (e.g., MMR, MMRV) Give SC. Varicella5 (e.g., Var, MMRV) Give SC. Hepatitis A (HepA) Give IM. Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM and MPSV4 SC. Human papillomavirus (e.g., HPV) Give IM. 5
Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. Give LAIV IN. Other
How to rrecor ecor d adult HepB ecord vaccine giv given en to 11-15 year olds
MMR MMR Var Var
1/15/91 10/15/01 10/15/01 10/15/07
P P P P
RA LA LA LA
0857M 0946M 0799M 0689M
MRK MRK MRK MRK
1/01/88 1/01/88 12/16/98 1/10/07
1/15/91 10/15/01 10/15/01 10/15/07
DLW PWS PWS JTA
MCV4
8/19/05
P
LA
U1766AA
SPI
4/4/05
8/19/05
DCP
HPV HPV HPV LAIV
9/12/06 11/14/06 3/14/07 10/15/07
P P P P
RA RA LA IN
0637F 0637F 0637F 500491P
MRK MRK MRK MED
9/6/06 9/5/06 2/02/07 10/04/07
9/12/06 11/14/06 3/14/07 10/15/07
MAT MAT JTA MAT
Tdap
7/9/06
P
LA
C2454AA
SPI
9/22/05
7/9/06
MAT
1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (Statesupported), or P (supported by Private insurance or other Private funds).
3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.
Distributed by the Immunization Action Coalition • (651) 647-9009 • www.immunize.org • www.vaccineinformation.org
Related Documents
Vaccination Records - Children And Teens
June 2020 6
Vaccination Records - Adults
June 2020 2
Teaching Children Teens And Adults
May 2020 7
Vaccination
November 2019 42