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Vaccine Administration Record
practice name and address
Before administering any vaccines, give the patient copies of all pertinent
Vaccine Information Statements (VISs) and make sure he/she understands
the risks and benefits of the vaccine(s). Always provide or update the patient’s
personal record card.
initials and title)
Date on VIS
(e.g., Tdap, Td)
(e.g., HepA, HepA-HepB)
(e.g., HepB, HepA-HepB)
(HPV2, HPV4, HPV9)
Measles, Mumps, Rubella
(MMR) Give Subcut.
(VAR) Give Subcut.
(e.g., MenACWY [MCV4],
MPSV4) Give MenACWY
Give MPSV4 Subcut.
(e.g., MenB) Give MenB
See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines
(e.g., travel vaccines).
How to Complete this Record
Trade Name and Manufacturer
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
vaccine (see table at right).
Havrix (GSK); Vaqta (Merck)
2. Record the funding source of the vaccine given as either F (federal),
Engerix-B (GSK); Recombivax HB (Merck)
S (state), or P (private).
3. Record the route by which the vaccine was given as either intramuscular
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral
Gardasil, Gardasil 9 (Merck)
(PO) and also the site where it was administered as either RA (right arm),
LA (left arm), RT (right thigh), or LT (left thigh).
4. Record the publication date of each VIS as well as the date the VIS is
Menactra (Sanofi Pasteur); Menveo (GSK)
given to the patient.
Menomune (Sanofi Pasteur)
5. To meet the space constraints of this form and federal requirements for
Bexsero (GSK); Trumenba (Pfizer)
documentation, a healthcare setting may want to keep a reference list of
vaccinators that includes their initials and titles.
6. For combination vaccines, fill in a row for each antigen in the combination.
Technical content reviewed by the Centers for Disease Control and Prevention
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
Item #P2023 (4/16)