Vaccine Administration Record for Children and Teens - Free Download
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This form was created by the Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org
Abbreviation Trade Name and Manufacturer
DTaP Daptacel (sano); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sano pasteur)
DT (pediatric) Generic DT (sano pasteur)
DTaP-HepB-IPV Pediarix (GSK)
DTaP/Hib TriHIBit (sano pasteur)
DTaP-IPV/Hib Pentacel (sano pasteur)
DTaP-IPV Kinrix (GSK)
HepB Engerix-B (GSK); Recombivax HB (Merck)
HepA-HepB Twinrix (GSK), can be given to teens age 18 and older
Hib ActHIB (sano pasteur); Hiberix (GSK); PedvaxHIB (Merck)
Hib-HepB Comvax (Merck)
Hib-MenCY MenHibrix (GSK)
IPV Ipol (sano pasteur)
PCV13 Prevnar 13 (Pzer)
PPSV23 Pneumovax 23 (Merck)
RV1 Rotarix (GSK)
RV5 RotaTeq (Merck)
Tdap Adacel (sano pasteur); Boostrix (GSK)
Td Decavac (sano pasteur); Generic Td (MA Biological Labs)
For additional copies, visit www.immunize.org/catg.d/p2022.pdf • Item #P2022 (4/14)
Vaccine Administration Record
for Children and Teens
Technical content reviewed by the Centers for Disease Control and Prevention
See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, and other vaccines (e.g., travel vaccines).
(Page 1 of 2)
How to Complete This Record
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vac-
cine (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 intramuscular
(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.
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.
Patient name:
Birthdate: Chart number:
Clinic name and address
Vaccine
Type of
Vaccine
1
Date given
(mo/day/yr)
Funding
Source
(F,S,P)
2
Route
& Site
3
Vaccine
Vaccine Information
Statement (VIS)
Vaccinator
5
(signature or
initials & title)
Lot # Mfr.
Date on VIS
4
Date given
4
Hepatitis B
6
(e.g., HepB, Hib-HepB,
DTaP-HepB-IPV)
Give IM.
3
Diphtheria, Tetanus,
Pertussis
6
(e.g., DTaP, DTaP/Hib,
DTaP-HepB-IPV, DT,
DTaP-IPV/Hib, Tdap,
DTaP-IPV, Td)
Give IM.
3
Haemophilus influen-
zae type b
6
(e.g., Hib, Hib-HepB,
DTaP-IPV/Hib, DTaP/Hib,
Hib-MenCY) Give IM.
3
Polio
6
(e.g., IPV, DTaP-HepB-
DTaP-IPV/Hib, DTaP-IPV)
Give IPV SC or IM.
3
Give all others IM.
3
Pneumococcal
(e.g., PCV7, PCV13, con-
jugate; PPSV23, polysac-
charide)
Give PCV IM.
3
Give PPSV SC or IM.
3
Rotavirus (RV1, RV5)
Give orally (po).
3
