page 1 0f 2
Vaccine Administration Record for Children and Teens
Patient name Birthdate
Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child’s parent or legal representative 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
Type of Vaccine1
Date vaccine Funding given Source (mo/day/yr) (F,S,P)2
Site3
Chart number
practice name and address
Vaccine Information Statement (VIS)
Vaccine Lot #
Mfr.
Date on VIS4
Date given4
Vaccinator5
(signature or initials and title)
Hepatitis B6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Give IM.7 Diphtheria, Tetanus, Pertussis6 (e.g., DTaP, DTaP/Hib, DTaP-HepB-IPV, DT, DTaP-IPV/Hib, DTaP-IPV, Tdap, Td) Give IM.7
Haemophilus influenzae type b6 (e.g., Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib, Hib-MenCY) Give IM.7 Polio6 (e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV) Give IPV Subcut or IM.7 Give all others IM.7 Pneumococcal (e.g., PCV7, PCV13, conjugate; PPSV23, polysaccharide) Give PCV IM.7 Give PPSV Subcut or IM.7 Rotavirus (RV1, RV5) Give orally (po).
• See page 2 to record measles-mumps-rubella, varicella, hepatitis A,
meningococcal, HPV, influenza, and other vaccines (e.g., travel vaccines).
Abbreviation DTaP
How to Complete this Record 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right). 2. Record the funding source of the vaccine given as either F (federal), S (state), or P (private). 3. Record the site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal). 4. Record the publication date of each VIS as well as the date the VIS is given to the patient. 5. To meet the space constraints of this form and federal requirements for 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. 7. IM is the abbreviation for intramuscular; Subcut is the abbreviation for subcutaneous.
DT (pediatric) DTaP-HepB-IPV DTaP-IPV/Hib DTaP-IPV HepB HepA-HepB Hib Hib-MenCY IPV PCV13 PPSV23 RV1 RV5 Tdap Td
Trade Name and Manufacturer Daptacel (Sanofi Pasteur); Infanrix (GlaxoSmithKline [GSK]); Tripedia (Sanofi Pasteur) Generic (Sanofi Pasteur) Pediarix (GSK) Pentacel (Sanofi Pasteur) Kinrix (GSK); Quadracel (Sanofi Pasteur) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHIB (Merck) MenHibrix (GSK) Ipol (Sanofi Pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (Sanofi Pasteur); Boostrix (GSK) Decavac, Tenivac (Sanofi Pasteur); Generic (MA Biological Labs)
Technical content reviewed by the Centers for Disease Control and Prevention
Immunization Action Coalition
Saint Paul, Minnesota 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org •
www.immunize.org/catg.d/p2022.pdf • Item #P2022 (4/16)
page 2 0f 2
Vaccine Administration Record for Children and Teens (continued)
Patient name Birthdate
Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child’s parent or legal representative 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
Type of Vaccine1
Date vaccine Funding given Source (mo/day/yr) (F,S,P)2
Site3
Chart number
practice name and address
Vaccine Information Statement (VIS)
Vaccine Lot #
Mfr.
Date on VIS4
Date given4
Vaccinator5
(signature or initials and title)
Measles, Mumps, Rubella6 (e.g., MMR, MMRV) Give Subcut.7
Varicella6 (e.g., VAR, MMRV) Give Subcut.7 Hepatitis A (HepA) Give IM.7 Meningococcal ACWY; CY (e.g., MenACWY [MCV4]; Hib-MenCY) Give MenACWY and Hib-MenCY IM.7 Meningococcal B (e.g., MenB) Give MenB IM.7
Human papillomavirus (e.g., HPV2, HPV4, HPV9) Give IM.7 Influenza (e.g., IIV3, IIV4, ccIIV3, RIV3, LAIV4) Give IIV3, IIV4, ccIIV3, and RIV3 IM.7 Give LAIV4 NAS.7
Other
• See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus
influenzae type b, polio, pneumococcal, and rotavirus vaccines.
How to Complete this Record 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine (see table at right). 2. Record the funding source of the vaccine given as either F (federal), S (state), or P (private). 3. Record the site where vaccine was administered as either RA (right arm), LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal). 4. Record the publication date of each VIS as well as the date the VIS is given to the patient. 5. To meet the space constraints of this form and federal requirements for 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. 7. IM is the abbreviation for intramuscular; Subcut is the abbreviation for subcutaneous.
Abbreviation
Trade Name and Manufacturer
MMR VAR MMRV HepA HepA-HepB HPV2 HPV4, HPV9
MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil, Gardasil 9 (Merck)
LAIV4 (live attenuated influenza vaccine, quadrivalent)
FluMist (MedImmune)
IIV3 (inactivated influenza vaccine, trivalent), IIV4 (inactivated influenza vaccine, quadrivalent), ccIIV3 (cell culture-based inactivated influenza vaccine, trivalent), RIV3 (inactivated recombinant influenza vaccine, trivalent)
Fluarix (GSK); Flublok (Protein Sciences Corp.); Afluria, Fluad, Flucelvax, Fluvirin (Seqirus); FluLaval (GSK); Fluzone (Sanofi Pasteur)
MenACWY HibMenCY MenB
Menactra (Sanofi Pasteur); Menveo (GSK) MenHibrix (GSK) Bexsero (GSK); Trumenba (Pfizer)
Immunization Action Coalition • Saint Paul, Minnesota • 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2022.pdf • Item #P2022 – page 2 (4/16)
Samantha Jo Swenson 3DWLHQWQDPH
Vaccine Administration Record for Children and Teens
6/1/2010
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practice name and address
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6/2/2010
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7/18/07
6/2/2010
Pediarix
JTA
8/2/2010
IM/RT
635A1
GSK
8/2/2010
DCP
Pediarix
F
7/18/07
10/2/2010
F
IM/RT
712A2
GSK
7/18/07
10/2/2010
DCP
Pediarix
12/2/2010
F
IM/RT
712A2
GSK
7/18/07
12/2/2010
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8/2/2010
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5/17/07
8/2/2010
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Pediarix
10/2/2010
635A1
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IM/RT
712A2
GSK
5/17/07
10/2/2010
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Pediarix
12/2/2010
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IM/RT
712A2
GSK
5/17/07
12/2/2010
DLW
DTaP
9/2/2011
F
IM/RT
365922
PMC
5/17/07
9/2/2010
RLV
DTaP
8/2/2015
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5/17/07
8/2/2015
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8/2/2010
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12/16/98
8/2/2010
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Hib
10/2/2010
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IM/RT
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MSD
12/16/98
10/2/2010
DCP
Hib
12/2/2010
F
IM/RT
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MSD
12/16/98
12/2/2010
DLW
Hib
9/2/2011
F
IM/LT
1543L
MSD
12/16/98
9/2/2011
RLV
635A1
GSK
1/1/00
8/2/2010
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712A2
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1/1/00
10/2/2010
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8/2/2010
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10/2/2010
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12/2/2010
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GSK
1/1/00
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8/2/2015
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11/8/11
8/2/2015
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PCV13
8/2/2010
F
IM/LT
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4/16/10
8/2/2010
DCP
PCV13
10/2/2010
F
IM/LT
7-5095-05A
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4/16/10
10/2/2010
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PCV13
12/2/2010
F
IM/LT
7-5095-05A
WYE
4/16/10
12/2/2010
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PCV13
9/2/2011
F
IM/LT
7-5095-05A
WYE
4/16/10
9/2/2010
RLV
RV5
8/2/2010
F
PO
05849
MSD
5/14/10
8/2/2010
DCP
RotaTeq
10/2/2010
F
PO
05849
MSD
5/14/10
10/2/2010
DCP
RotaTeq
12/2/2010
F
PO
05849
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5/14/10
12/2/2010
DLW
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Abbreviation
Trade Name and Manufacturer
DTaP
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Date vaccine Funding Source given PRGD\\U )63
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page 2 0f 2
Samantha Jo Swenson 3DWLHQWQDPH
Site3
practice name and address
Metropolitan Pediatrics 6547 Grand Avenue Big City, AB 35791 Vaccine Information Statement (VIS)
Vaccine
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7/2/2010
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5/21/10
8/2/2015
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5/21/10
7/2/2010
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8/2/2015
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5/21/10
8/2/2015
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Havrix
7/2/2011
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GSK
3/21/06
7/2/2010
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Vaqta
1/5/2012
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3/21/06
1/5/2011
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Fluzone
12/2/2010
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8/10/10
12/1/2010
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Fluzone
1/5/2011
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8/10/10
1/5/2011
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IIV3
9/15/2011
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7/26/11
9/15/2011
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9/10/2015
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7/2/2012 9/10/2012
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GSK
8/19/2014 10/1/2014
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Abbreviation
Trade Name and Manufacturer
005 9$5 0059 HepA HepA-HepB +39 +39+39
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