Vaccine Administration Record for Adults - Free Download
4.5,
4353
votes
Please vote for this template if it helps you.
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 Administration Record
for Adults
For additional copies, visit www.immunize.org/catg.d/p2023.pdf • Item #P2023 (4/14)
Vaccine
Type of Vaccine
1
Date given
(mo/day/yr)
Funding
source
(F,S,P)
2
Vaccine
Vaccinator
5
(signature or
initials & title)
Vaccine Information
Statement (VIS)
Tetanus,
Diphtheria, Pertussis
(e.g., Td, Tdap)
Give IM.
3
Hepatitis A
6
(e.g., HepA, HepA-HepB)
Give IM.
3
Hepatitis B
6
(e.g., HepB, HepA-HepB)
Give IM.
3
Measles, Mumps,
Rubella
(MMR) Give SC.
3
Varicella
(VAR) Give SC.
3
Pneumococcal
(e.g., PCV13, conjugate;
PPSV23, polysaccharide)
Give PCV13 IM.
3
Give PPSV23 IM or SC.
3
Meningococcal
(e.g., MenACWY, conjugate;
MPSV4, polysaccharide)
Give MenACWY IM.
3
Give MPSV4 SC.
3
Human papillomavirus
(HPV2, HPV4)
Give IM.
3
This form was created by the Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org
Technical content reviewed by the Centers for Disease Control and Prevention
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 route by which the vaccine was given as either intramuscu-
lar (IM), subcutaneous (SC), intradermal (ID), intranasal (IN), or oral
(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 given to
the patient.
5. To meet the space constraints of this form and federal requirements for docu-
mentation, 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.
See page 2 to record influenza, Hib, zoster, and other vaccines (e.g., travel vaccines).
Abbreviation Trade Name and Manufacturer
Tdap Adacel (sano pasteur); Boostrix (GlaxoSmithKline [GSK])
Td Decavac (sano pasteur); generic Td (MA Biological Labs)
HepA Havrix (GSK); Vaqta (Merck)
HepB Engerix-B (GSK); Recombivax HB (Merck)
HepA-HepB Twinrix (GSK)
HPV2 Cervarix (GSK)
HPV4 Gardasil (Merck)
MMR
MMRII (Merck)
VAR Varivax (Merck)
PCV13, PPSV23 Prevnar 13 (Pzer); Pneumovax 23 (Merck)
MenACWY Menactra (sano pasteur); Menveo (Novartis)
MPSV4 Menomune (sano pasteur)
(Page 1 of 2)
Lot # Mfr.
Date on VIS
4
Date given
4
Route
3
& Site
3
Patient name:
Birthdate: Chart number:
Clinic name and address
