Vaccine Administration Record For Adults Page 2
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Vaccine Administration Record
Patient name
for Adults
Birthdate
Chart number
(continued)
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.
Vaccine Information
Date vaccine
Funding
Route
3
Vaccine
Vaccinator
5
Type of
Statement (VIS)
Vaccine
given
Source
and
(signature or
Vaccine
1
(mo/day/yr)
(F,S,P)
Site
2
3
initials and title)
Date on VIS
4
Lot #
Mfr.
Date given
4
Influenza
(e.g., IIV3, IIV4, ccIIV3,
RIV3, LAIV4)
Give IIV3, IIV4, ccIIV3,
and RIV3 IM.
3
Give LAIV4 NAS.
3
Pneumococcal conjugate
3
(e.g., PCV13) Give PCV13 IM.
Pneumococcal polysac-
charide (e.g., PPSV23)
Give PPSV23 IM or
Subcut.
3
Zoster (HZV) Give Subcut.
3
Hib Give IM.
3
Other
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See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella,
MenACWY, and MenB vaccines.
Abbreviation
Trade Name and Manufacturer
How to Complete this Record
IIV3 (inactivated influenza
vaccine, trivalent); IIV4
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each
(inactivated influenza
Fluarix (GSK); Flublok (Protein Sciences Corp.);
vaccine, quadrivalent);
vaccine (see table at right).
Afluria, Fluad, Flucelvax, Fluvirin (Seqirus); FluLaval
ccIIV3 (cell culture-based
(GSK); Fluzone, Fluzone Intradermal, Fluzone
2. Record the funding source of the vaccine given as either F (federal),
inactivated influenza
High-Dose (Sanofi Pasteur)
S (state), or P (private).
vaccine, trivalent); RIV3
(inactivated recombinant
3. Record the route by which the vaccine was given as either intramuscular
influenza vaccine, trivalent)
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), or oral
LAIV (live attenuated
(PO) and also the site where it was administered as either RA (right arm),
influenza vaccine, quad-
FluMist (MedImmune)
LA (left arm), RT (right thigh), or LT (left thigh).
rivalent]
4. Record the publication date of each VIS as well as the date the VIS is
PCV13
Prevnar 13 (Pfizer)
given to the patient.
PPSV23
Pneumovax 23 (Merck)
5. To meet the space constraints of this form and federal requirements for
HZV (shingles)
Zostavax (Merck)
documentation, a healthcare setting may want to keep a reference list of
ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib
Hib
(Merck)
vaccinators that includes their initials and titles.
651 - 647 - 9009
Immunization Action Coalition
Saint Paul, Minnesota
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/catg.d/p2023.pdf
Item #P2023 – page 2 (4/16)
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