Form Mg-5667 - Adult Immunization Record Form Page 2
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2Section to be completed by the immunization provider:
Name of client: ______________________________________________________
PHIN #: _____________________________________
Immunization Record: The vaccine(s) identified below were administered:
Data
Vaccine
Number
Manufacturer
Lot #
Site
Route
Dose
Date
Provider signature
Clerk’s
in series
y/m/d
entry
initials
TB Skin Test
Mantoux
Date Planted
Lot #
Dose/Route/Site
Initial
Date Read
Positive
Negative
Initial
Supplementary Information
Date
Notes (include immunization refusal)
Signature
Important Immunization Tips:
Before
Vaccine storage and handling practice as per the manufacturers recommendations
Indications and contraindications reviewed
Manitoba Health anaphylaxis protocol in non-hospital setting near
Anaphylaxis kit ready and near
Telephone near in case of emergency
After
Vaccine recipient under supervision for 15 minutes after the immunization
Documentation immunization (consent form, immunization record, client’s file) completed
Data entry of immunization via billing Manitoba Health (doctors and medical clinics) or data entry in Panorama by
Public Health completed
Phone number(s) for post-immunization questions/concerns provided to client or his/her substitute decision-maker
Immunization References for Health Care Professionals:
Current “Canadian Immunization Guide” by the National Advisory Committee on Immunization (NACI)
Current “Your Child’s Best Shot, A parent’s guide to vaccination’’ by the Canadian Paediatric Society (CPS)
Current “Red Book, Report Committee on Infectious Diseases’’ by the American Academy of Pediatrics
Canada Communicable Disease Reports (CCDR) by Health Canada
Morbidity Mortality Weekly Reports (MMWR) by U.S. Centers for Disease Control and Prevention
Immunization Web Sites for Health Care Professionals and for the public:
Manitoba Health Public Health Branch
Health Canada Division of Immunization & Respiratory Diseases
U.S. Centers for Disease Control & Prevention:
World Health Organization:
National Immunization Program
Vaccines, Immunization and Biologicals
MG-5667 (Revised June 2016)
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Parent category: Medical