Vaccine Administration Record (Page 2 of 2) in pdf

First name:

Last name:

SECTION D

HEALTHCARE PROVIDER ONLY

Complete BEFORE vaccine administration

Vaccine

Route

Dosage

Lot #

Expiration date

0.25mL: 24-36 months

Influenza

intramuscular

0.5mL: > 36 months

Influenza (intradermal)

intradermal

0.1mL (prefilled)

Influenza (nasal)

intranasal

0.1mL each nostril

Influenza (high dose)

intramuscular

0.5mL (prefilled)

Chicken pox (varicella)

subcutaneous

0.5mL

1mL: Adults ≥19 years

Hepatitis A

intramuscular

0.5mL: Adolescents ≤ 18 years

1mL: Adults ≥20 years

Hepatitis B

intramuscular

0.5mL: Adolescents ≤ 19 years

Hepatitis A/B (Twinrix

)

intramuscular

1mL: Adults ≥18 years

Human papillomavirus

intramuscular

0.5mL

Japanese encephalitis

intramuscular

0.5mL

intramuscular

Meningococcal (meningitis)

(subcutaneous –

0.5mL

Menomune

only)

MMR (measles, mumps, rubella)

subcutaneous

0.5mL

Pneumococcal (Pneumovax

)

intramuscular

0.5mL

Pneumococcal (Prevnar

)

intramuscular

0.5mL (prefilled)

Polio

intramuscular

0.5mL

Rabies

intramuscular

1mL

Shingles (herpes zoster)

subcutaneous

0.65mL

Td (tetanus and diphtheria)

intramuscular

0.5mL

Tdap (tetanus, diphtheria

intramuscular

0.5mL

and pertussis)

1 capsule by mouth every other

Typhoid (live oral)

orally

day until all taken

Typhoid (inactive injectable)

intramuscular

0.5mL

Yellow fever

subcutaneous

0.5mL

Needle size

Patient gender/weight

Intramuscular injection is in the deltoid

to 1 inch needle

Female or male weighing less than 130 lbs

‡

1 to 1½ inch needle

Female 130-200 lbs; male 130-260 lbs

1½ inch needle

Female 200+ lbs; male 260+ lbs

Subcutaneous injection is in the upper arm (posterolateral)

All patients

inch needle

Intradermal injection is in the deltoid

Prefilled syringe

All patients

A 5/8 inch needle may be used for patients weighing less than 130 lbs (<60kg) for IM injection in the deltoid muscle only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.

‡

I have verified the immunization(s) that the patient requested meets state, age and vaccine restrictions.

Initial here:

I have verified the requested immunization is the same as the product prepared.

Initial here:

I have verified the expiration date of the product is greater than today’s date.

Initial here:

For Zostavax

, MMR II

, Varivax

, YF-Vax

, Menveo

, Imovax

and Rabavert

, I have reconstituted the vaccine following the package

insert’s instructions.

Initial here:

For patients younger than 9 years of age requesting the influenza vaccine:

Did you verify if a second dose is needed?

Yes

If this is the second dose, have 28 days elapsed since the first dose?

Yes

Complete AFTER vaccine administration

Vaccine

NDC

Dosage

Site of administration

VIS published date

(circle site)

L / R IM/SQ

Immunizer name (print):

Immunizer signature:

Title:

If applicable, intern name (print):

Administration date:

Date VIS given to patient:

Immunization billing notes section (complete all applicable fields)

Insurance name:

Payer ID/BIN:

Cardholder name:

Recipient ID:

Group ID:

Notes

14IM0007

Vaccine Administration Record Page 2

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