Vaccine Screening Questionnaire Template Page 2
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1
2MEDICAL RECORD - SUPPLEMENTAL MEDICAL DATA
For use of this form, see requiring document. Form is not valid without Requiring Document, Issuance Date, Local Form Number, and Edition Date.
Date
PATIENT / PARENT SIGNATURE - Patient / Parent has been instructed on possible side effects and
post immunization care. Required VIS forms have been provided to the patient / parent.
Yes / No
Signature of Patient / Parent:__________________________
Stamp & signature of interviewer/vaccinator:
Actions taken / medication administered:
Immunocompromised Vaccination Guidance Table
Symptomatic
Severly
Post-Solid Organ
Chronic Hepatic
Asymptomatic
Renal
Vaccine Type
HIV Infection
Immunocompromised
Transplant / Chronic
Asplenia
Disease, Cirrhosis,
HIV
Failure
/ AIDS
(Non-HIV Related)
Immunosuppressive Therapy
Diabetes
Live Vaccines
Bacille Calmette Guérin
X
X
X
X
U
U
U
X
X
X
X
X
X
Influenza (LAIV)
U
W
MMR (MR/M/R) [1]
R
X
X
U
U
U
Rotavirus
X
X
X
X
X
X
U
Typhoid, Ty21a
X
X
X
X
U
U
U
Varicella [2]
U
X
X
X
U
U
U
W
Yellow Fever [3]
X
X
X
U
U
U
Smallpox
X
X
X
X
U
X
U
Killed (Inactivated) Vaccines
Anthrax
U
U
U
U
U
U
U
Haemophilus
C [4]
C [4]
R
R
R
U
U
Influenzae (HIB)
Hepatitis A
U [5]
U [5]
U
U
U [5]
U [5]
U [5]
Hepatitis B
U [5]
U [5]
U
U
U
R [6]
U
Influenza (inactivated)
R
R
R
R
R
R
R
Japanese encephalitis
U
U
U
U
U
U
U
Meningococcal polysaccharide or
C
C
U
U
R
U
U
conjugate
Pneumococcal polysaccharide or
R
R
R
R
R
R
R
conjugate
Polio (IPV)
U
U
U
U
U
U
U
Rabies
U
U
U
U
U
U
U
Td or Tdap, Dtap
R
R
R
R
R
R
R
Typhoid, Vi
U
U
U
U
U
U
U
C = Consider W = Warning
Legend:
R = Recommended for all in this category
U = Use as indicated for normal hosts
X = Contraindicated
[1] MMR vaccination should be considered for all symptomatic HIV-infected persons with CD4 counts >200/mL without evidence of measles immunity. Immune globulin may be
administered for short-term protection of those facing high risk of measles and for whom MMR vaccine is contraindicated.
[2] Varicella vaccine should not be administered to persons who have cellular immunodeficiencies, but persons with impaired humoral immunity (including congenital or acquired
hypo- or dysglobulinemia) may be vaccinated. Immuncompromised hosts should receive two doses of vaccine spaced at 3-month intervals.
[3] Yellow fever vaccine. See detail in text.
[4] Decision should be based on consideration of the individual patient’s risk of Hib disease and the effectiveness of the vaccine for that person. In some settings, the incidence of Hib
disease may be higher among HIV-infected adults than non-HIV-infected adults, and the disease can be severe in these patients.
[5] Routinely indicated for all men who have sex with men, persons with multiple sexual partners, hemophiliacs, patients with chronic hepatitis, and injection drug users.
[6] Use special double-dose vaccine formulation. Test for anti-Hbs response after vaccination and revaccinate if initial response is absent.
Privacy Act Statement. AUTHORITY: Title 10 U.S. Code §§ 5014 and 5020 PURPOSE: To document vaccination administration in the health record. Disclosure of Social Security
Account Number is voluntary; however it is necessary to document vaccination in the Health Record to be in compliance with 42 U.S. Code. It is further identify the individual providing
the information and receiving the care. It is important that the information be correct. Incorrect information could result in documentation, reporting and payment errors. Incorrect
information also could make it hard to be sure that the agency is giving you quality services. If you choose not to provide information, there is no federal requirement for the agency to
provide you services. THIS STATEMENT IS NOT A CONSENT FORM. IT WILL NOT BE USED TO RELEASE OR TO USE YOUR HEALTH CARE INFORMATION.
PRACTITIONER'S NAME
DATE
PRACTITIONER'S SIGNATURE
PATIENT'S IDENTIFICATION: (For typed or written entries, give:
HOSPITAL OR MEDICAL FACILITY
STATUS
Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.)
DEPARTMENT / SERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME
SSN
RELATIONSHIP TO SPONSOR
NAVMED 6000/5 (09-2008)
Category
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