Vaccine Administration Record for Children and Teens

1 Page 1 0f 2. Vaccine Administration Record Patient name Birthdate Chart number for Children and Teens practice name and address 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. Date Vaccine Funding Vaccine Vaccine Information Vaccinator5. Type of Statement (VIS). Vaccine Vaccine1. given Source Site3 (signature or (mo/day/yr) (F,S,P)2 Lot # Mfr. Date on VIS4 Date given4 initials and title). Hepatitis B6. ( , HepB, Hib-HepB, DTaP-HepB-IPV). Give Diphtheria, Tetanus, Pertussis6. ( , DTaP, DTaP/Hib, DTaP-HepB-IPV, DT, DTaP-IPV/Hib, DTaP-IPV, Tdap, Td) Give Haemophilus influenzae type b6.

2 ( , Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib, Hib-MenCY) Give Polio6. ( , IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV). Give IPV Subcut or Give all others Pneumococcal ( , PCV7, PCV13, conjugate; PPSV23, polysaccharide). Give PCV Give PPSV Subcut or Rotavirus (RV1, RV5). Give orally (po). See page 2 to Record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, and other vaccines ( , travel vaccines). Abbreviation Trade Name and Manufacturer Daptacel (Sanofi Pasteur); Infanrix (GlaxoSmithKline [GSK]);. DTaP. How to Complete this Record Tripedia (Sanofi Pasteur). DT (pediatric) Generic (Sanofi Pasteur). 1. Record the generic abbreviation ( , Tdap) or the trade name for each DTaP-HepB-IPV Pediarix (GSK).

3 Vaccine (see table at right). DTaP-IPV/Hib Pentacel (Sanofi Pasteur). 2. Record the funding source of the Vaccine given as either F (federal), DTaP-IPV Kinrix (GSK); Quadracel (Sanofi Pasteur). S (state), or P (private). HepB Engerix-B (GSK); Recombivax HB (Merck). 3. Record the site where Vaccine was administered as either RA (right arm), HepA-HepB Twinrix (GSK); can be given to Teens age 18 and older Hib ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHIB (Merck). LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal). Hib-MenCY MenHibrix (GSK). 4. Record the publication date of each VIS as well as the date the VIS is IPV Ipol (Sanofi Pasteur). given to the patient. PCV13 Prevnar 13 (Pfizer). 5. To meet the space constraints of this form and federal requirements for PPSV23 Pneumovax 23 (Merck).

4 Documentation, a healthcare setting may want to keep a reference list of RV1 Rotarix (GSK). vaccinators that includes their initials and titles. RV5 RotaTeq (Merck). 6. For combination vaccines, fill in a row for each antigen in the combination. Tdap Adacel (Sanofi Pasteur); Boostrix (GSK). 7. IM is the abbreviation for intramuscular; Subcut is the abbreviation for Td Decavac, Tenivac (Sanofi Pasteur); Generic (MA Biological Labs). subcutaneous. Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota 651- 647- 9009 . Item #P2022 (4/16). page 2 0f 2. Vaccine Administration Record Patient name for Children and Teens (continued) Birthdate Chart number practice name and address 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).

5 Always provide or update the patient's personal Record card. Date Vaccine Funding Vaccine Vaccine Information Vaccinator5. Type of Statement (VIS). Vaccine Vaccine1. given Source Site3 (signature or (mo/day/yr) (F,S,P)2 Lot # Mfr. Date on VIS4 Date given4 initials and title). Measles, Mumps, Rubella6. ( , MMR, MMRV). Give Varicella6 ( , VAR, MMRV) Give Hepatitis A (HepA). Give Meningococcal ACWY; CY. ( , MenACWY [MCV4];. Hib-MenCY). Give MenACWY and Hib-MenCY Meningococcal B ( , MenB) Give MenB Human papillomavirus ( , HPV2, HPV4, HPV9) Give Influenza ( , IIV3, IIV4, ccIIV3, RIV3, LAIV4). Give IIV3, IIV4, ccIIV3, and RIV3 Give LAIV4 Other See page 1 to Record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus Abbreviation Trade Name and Manufacturer influenzae type b, polio, pneumococcal, and rotavirus vaccines.

6 MMR MMRII (Merck). How to Complete this Record VAR Varivax (Merck). MMRV ProQuad (Merck). 1. Record the generic abbreviation ( , Tdap) or the trade name for each HepA Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck). Vaccine (see table at right). HepA-HepB Twinrix (GSK). 2. Record the funding source of the Vaccine given as either F (federal), HPV2 Cervarix (GSK). S (state), or P (private). HPV4, HPV9 Gardasil, Gardasil 9 (Merck). 3. Record the site where Vaccine was administered as either RA (right arm), LAIV4 (live attenuated influ- FluMist (MedImmune). LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal). enza Vaccine , quadrivalent). 4. Record the publication date of each VIS as well as the date the VIS is IIV3 (inactivated influenza vac- cine, trivalent), IIV4 (inactivated given to the patient.)

7 Influenza Vaccine , quadrivalent), Fluarix (GSK); Flublok (Protein Sciences Corp.);. ccIIV3 (cell culture-based Afluria, Fluad, Flucelvax, Fluvirin (Seqirus);. 5. To meet the space constraints of this form and federal requirements for inactivated influenza Vaccine , FluLaval (GSK); Fluzone (Sanofi Pasteur). trivalent), RIV3 (inactivated documentation, a healthcare setting may want to keep a reference list of recombinant influenza Vaccine , vaccinators that includes their initials and titles. trivalent). 6. For combination vaccines, fill in a row for each antigen in the combination. MenACWY Menactra (Sanofi Pasteur); Menveo (GSK). 7. IM is the abbreviation for intramuscular; Subcut is the abbreviation for HibMenCY MenHibrix (GSK).

8 MenB Bexsero (GSK); Trumenba (Pfizer). subcutaneous. Immunization Action Coalition Saint Paul, Minnesota 651- 647- 9009 Item #P2022 page 2 (4/16). page 1 0f 2. Samantha Jo Swenson Vaccine Administration Record 3 DWLHQW QDPH. 6/1/2010. for Children and Teens %LUWKGDWH &KDUW QXPEHU. practice name and address %HIRUH DGPLQLVWHULQJ DQ\ YDFFLQHV JLYH FRSLHV RI DOO SHUWLQHQW 9 DFFLQH . Metropolitan Pediatrics ,QIRUPDWLRQ 6 WDWHPHQWV 9,6V WR WKH FKLOG V SDUHQW RU OHJDO UHSUHVHQWDWLYH . 6547 Grand Avenue DQG PDNH VXUH KH VKH XQGHUVWDQGV WKH ULVNV DQG EHQH WV RI WKH YDFFLQH V . Big City, AB 35791. $OZD\V SURYLGH RU XSGDWH WKH SDWLHQW V SHUVRQDO UHFRUG FDUG . Date Vaccine Funding Vaccine Vaccine Information Vaccinator5. Type of Statement (VIS).

9 Vaccine Vaccine1. given Source Site3 VLJQDWXUH RU. PR GD\ \U ) 6 3 /RW 0IU 'DWH RQ 9,64 'DWH JLYHQ4 LQLWLDOV DQG WLWOH Hepatitis B6 HepB 6/2/2010 P IM/RT 0651M MRK 7/18/07 6/2/2010 JTA. H J +HS% +LE +HS% Pediarix IM/RT GSK DCP. 8/2/2010 F 635A1 7/18/07 8/2/2010. '7D3 +HS% ,39 *LYH ,0 7 Pediarix 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 DLW. Diphtheria, Tetanus, Pediarix 8/2/2010 F IM/RT 635A1 GSK 5/17/07 8/2/2010 DCP. Pertussis6 Pediarix 10/2/2010 IM/RT 712A2 GSK 10/2/2010 DCP. F 5/17/07. H J '7D3 '7D3 +LE . '7D3 +HS% ,39 '7 Pediarix 12/2/2010 F IM/RT 712A2 GSK 5/17/07 12/2/2010 DLW. '7D3 ,39 +LE '7D3 ,39 DTaP 9/2/2011 F IM/RT 365922 PMC 5/17/07 9/2/2010 RLV.

10 7 GDS 7G *LYH ,0 7. DTaP 8/2/2015 F IM/RA 376912 PMC 5/17/07 8/2/2015 JTA. +DHPRSKLOXV LQ XHQ]DH Hib 8/2/2010 F IM/RT 1492L MSD 12/16/98 8/2/2010 DCP. type b6 Hib 10/2/2010 F IM/RT 1492L MSD 12/16/98 10/2/2010 DCP. H J +LE +LE +HS% . '7D3 ,39 +LE '7D3 +LE Hib 12/2/2010 F IM/RT 1492L MSD 12/16/98 12/2/2010 DLW. +LE 0HQ&< *LYH ,0 7 Hib 9/2/2011 F IM/LT 1543L MSD 12/16/98 9/2/2011 RLV. Polio6 Pediarix 8/2/2010 F IM/RT 635A1 GSK 1/1/00 8/2/2010 DCP. H J ,39 '7D3 +HS% ,39 Pediarix 10/2/2010 IM/RT GSK DCP. F 712A2 1/1/00 10/2/2010. '7D3 ,39 +LE '7D3 ,39 Pediarix 12/2/2010 F IM/RT 712A2 GSK 1/1/00 12/2/2010 DLW. *LYH ,39 6 XEFXW RU ,0 7. *LYH DOO RWKHUV ,0 7 IPV 8/2/2015 F IM/LA U4569-8 PMC 11/8/11 8/2/2015 RLV. Pneumococcal PCV13 8/2/2010 F IM/LT 7-5095-05A WYE 4/16/10 8/2/2010 DCP.