Vaccines Administered Log
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1
2M M
Y Y
VACCINES ADMINISTERED LOG
Report Month:
Page
of
Contact Person:
-
Federal ID #:
-
Contact Phone:
(
)
Fill in this circle if zero doses given this month:
Provider Name:
Street Address:
Eligibility/Insurance
City:
(Fill in Only One)
Vaccine Administered
(Only For State Supplied Vaccine, otherwise use “Notes”)
Patient Name
Birth Date
Service Date
Please Print
M M / D D / Y Y Y Y
M M / D D / Y Y
Last
A
M
N
U
H
I
First
MI
Notes
Last
A
M
N
U
H
I
First
MI
Notes
Last
A
M
N
U
H
I
First
MI
Notes
Last
A
M
N
U
H
I
MI
Notes
First
Last
A
M
N
U
H
I
First
MI
Notes
Last
A
M
N
U
H
I
MI
Notes
First
Last
A
M
N
U
H
I
First
MI
Notes
Column Totals:
These logs must be received by the Immunization Branch by the 10th of each month.
See back for other instructions.
Part 1 (white) Immunization Branch, Part 2 (yellow) Immunization Branch, Part 3
(pink) Provider
VAL122, 5/2016
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