Vaccine Administration Record (Var) - Walgreens Page 2
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1
2SECTION D
HEALTHCARE PROVIDER ONLY
Complete BEFORE vaccine administration
Vaccine
Route
Dosage
Lot #
Expiration Date
Influenza (MDV)
Intramuscular
0.5mL
Influenza (Intradermal)
Intradermal
Prefilled
Influenza (Nasal)
Intranasal
0.1mL each nostril
Influenza (High dose)
Intramuscular
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
Subcutaneous
0.5mL
Intramuscular
Meningococcal (Meningitis)
(Subcutaneous –
0.5mL
Menomune Only)
MMR (Measles, Mumps, Rubella)
Subcutaneous
0.5mL
Pneumococcal (Pneumonia)
Intramuscular
0.5mL
Polio
Intramuscular
0.5mL
Shingles (Herpes Zoster)
Subcutaneous
0.65mL
Td (Tetanus and diphtheria)
Intramuscular
0.5mL
Tdap (Tetanus, diphtheria
Intramuscular
0.5mL
and pertussis)
Typhoid (Live Oral)
Orally
Typhoid (Inactive injectable)
Intramuscular
0.5mL
Yellow fever
Subcutaneous
0.5mL
Needle size
Age
Intramuscular injection is in the deltoid
to 1¼ inch needle
3-18 y/o ( inch needle for patients weighing less than 130 lbs)
1 to 1½ inch needle
19 y/o and older (Female 130-200 lbs; Male 130-260 lbs)
1½ inch needle
19 y/o and older (Female 200+ lbs; Male 260+ lbs)
Subcutaneous injection is in the upper arm (postero-lateral)
All ages
inch needle
Intradermal injection is in the deltoid
Prefilled Syringe
All ages
I have verified the immunization(s) that the patient requested meets state, age and vaccine restrictions.
Initial here:
I have verified the requested immunization(s) 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
, I have reconstituted the vaccine following the package insert’s instructions.
Initial here:
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®
®
®
®
For patients younger than 9 years of age requesting the influenza vaccine:
Did you verify if a second dose is needed?
Yes
No
If this is the second dose, have 28 days elapsed since the first dose?
Yes
No
Complete AFTER vaccine administration
Rx #
Vaccine
NDC
Dosage
Site of Injection
VIS Published Date
(circle site)
Immunizer Name (print):
Immunizer Signature:
RPh/PharmD/RN/LPN/LVN/NP/PA
(circ l e o ne )
If Applicable, Intern Name (print):
Administration Date:
Date VIS Given to Patient:
Notes
13FL0002
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