Vaccine Administration Record For Adults Page 3
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Mahamud Omar
Vaccine Administration Record
5/31/1971
for Adults
practice name and address
Small Rural Clinic
135 County Road D
Small Town, CD 46902
Vaccine Information
Date vaccine
Funding
Route
3
Vaccine
Vaccinator
5
Type of
Statement (VIS)
Vaccine
given
Source
and
Vaccine
1
Site
3
P
Td
IM/LA
UO376AA
AVP
JTA
8/1/2002
6/10/1994 8/1/2002
Tetanus,
Diphtheria, Pertussis
Td
P
IM/LA
UO376AA
AVP
RVO
9/1/2002
6/10/1994 9/1/2002
Td
P
IM/LA
UO376AA
AVP
TAA
3/1/2003
6/10/1994 3/1/2003
3
P
Tdap
IM/LA AC52B030AA
GSK
JA
3/1/2015
2/24/2015 3/1/2015
Hepatitis A
6
3
Hepatitis B
6
3
Human papillomavirus
3
MMR
0025L
MSD
JTA
P
8/1/2002
6/13/2002 8/1/2002
Subcut/RA
Measles, Mumps, Rubella
3
MMR
0025L
MSD
TAA
P
11/1/2002
Subcut/RA
6/13/2002 11/1/2002
VAR
0799M
MSD
JTA
8/1/2002
P
12/16/1998 8/1/2002
Varicella
Subcut/LA
3
VAR
0689M
MSD
12/16/1998 11/1/2002
TAA
11/1/2002
P
Subcut/LA
MenACWY
P
M28011
NOV
LTB
7/12/2011
IM/RA
1/2/2008
7/12/2011
Meningococcal ACWY
Menveo
P
M12115
NOV
RVO
7/15/2016
IM/LA
3/31/16
7/15/2016
7
7
J296203
PFR
RVO
MenB
1/14/2016
P
IM/LA
8/14/2015 1/14/2016
Meningococcal B
Trumenba
J296203
PFR
RVO
3/15/2016
P
IM/LA
8/14/2015 3/15/2016
7
Trumenba
J296203
PFR
RVO
7/15/2016
P
IM/RA
8/14/2015
7/15/2016
See page 2
How to Complete this Record
Abbreviation
Trade Name and Manufacturer
Tdap
Td
HepA
T
Immunization Action Coalition
Saint Paul, Minnesota 651 - 647 - 9009
p
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