Vaccine Administration Record For Adults Page 4

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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
Vaccinator
Vaccine
5
Type of
Statement (VIS)
Vaccine
given
Source
and
Vaccine
1
Site
3
Flulaval
F
GSK
PWS
10/2/2009
IM/RA
2F600411
8/11/09
10/2/09
10092224P
NOV
H1N1
P
DLW
12/7/2009
IM/RA
12/7/09
10/2/09
Afluria
P
06949111A
CSL
TAA
9/12/2010
IM/RA
8/10/10
9/12/10
2F600411
GSK
Flulaval
P
JTA
10/1/2011
IM/LA
8/10/11
10/1/11
3
M50907
CSL
KKC
IIV3
P
9/5/2012
IM/RA
7/2/12
9/5/12
3
PSC
350603F
DCP
RIV3
P
7/26/13
12/2/13
12/2/2013
IM/RA
PMC
JTA
IIV4
P
UI196AA
8/19/14
10/5/14
10/5/2014
IM/RA
NOV
111773P
DCP
IIV4
P
8/7/15
11/2/15
11/2/2015
IM/LA
Pneumococcal conjugate
PCV13
P
7-5096-o6A
WYE
CJP
11/1/2012
IM/LA
4/16/10
11/1/12
3
663012/1163X
MSD
PPSV23
P
DLW
9/10/2011
IM/LA
10/6/09
9/10/11
Pneumococcal polysac-
charide
663860/1626X
PPSV23
MSD
P
TAA
9/15/2015
IM/LA
4/24/15
9/15/15
3
Zoster
3
D05561
PMC
P
MAT
ActHIB
11/1/2014
IM/RA
2/4/14
11/1/14
Hib
3
Other
See page 1
Abbreviation
Trade Name and Manufacturer
How to Complete this Record
Immunization Action Coalition Saint Paul, Minnesota 651 - 647 - 9009
p
1

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