page 1 0f 2
Vaccine Administration Record
for Adults
Patient name
Birthdate
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
Type of
Vaccine1
Date vaccine Funding
given
Source
(mo/day/yr) (F,S,P)2
Route3
and
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)
Tetanus,
Diphtheria, Pertussis
(e.g., Tdap, Td)
Give IM.3
Hepatitis A6
(e.g., HepA, HepA-HepB)
Give IM.3
Hepatitis B6
(e.g., HepB, HepA-HepB)
Give IM.3
Human papillomavirus
(HPV2, HPV4, HPV9)
Give IM.3
Measles, Mumps, Rubella
(MMR) Give Subcut.3
Varicella
(VAR) Give Subcut.3
Meningococcal ACWY
(e.g., MenACWY [MCV4],
MPSV4) Give MenACWY
IM.7 Give MPSV4 Subcut.7
Meningococcal B
(e.g., MenB) Give MenB
IM.7
• See page 2 to record influenza, pneumococcal, zoster, Hib, and other vaccines
(e.g., travel vaccines).
How to Complete this Record
Abbreviation
Trade Name and Manufacturer
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 intramuscular
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), 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
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.
Tdap
Td
HepA
HepB
HepA-HepB
HPV2
HPV4, HPV5
MMR
VAR
MenACWY
MPSV4
MenB
Adacel (Sanofi Pasteur); Boostrix (GlaxoSmithKline [GSK])
Decavac, Tenivac (Sanofi Pasteur); generic Td (MA Biological Labs)
Havrix (GSK); Vaqta (Merck)
Engerix-B (GSK); Recombivax HB (Merck)
Twinrix (GSK)
Cervarix (GSK)
Gardasil, Gardasil 9 (Merck)
MMRII (Merck)
Varivax (Merck)
Menactra (Sanofi Pasteur); Menveo (GSK)
Menomune (Sanofi Pasteur)
Bexsero (GSK); Trumenba (Pfizer)
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/p2023.pdf • Item #P2023 (4/16)
page 2 0f 2
Vaccine Administration Record
for Adults (continued)
Patient name
Birthdate
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
Type of
Vaccine1
Date vaccine Funding
given
Source
(mo/day/yr) (F,S,P)2
Route3
and
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)
Influenza
(e.g., IIV3, IIV4, ccIIV3,
RIV3, LAIV4)
Give IIV3, IIV4, ccIIV3,
and RIV3 IM.3
Give LAIV4 NAS.3
Pneumococcal conjugate
(e.g., PCV13) Give PCV13 IM.3
Pneumococcal polysaccharide (e.g., PPSV23)
Give PPSV23 IM or
Subcut.3
Zoster (HZV) Give Subcut.3
Hib Give IM.3
Other
• See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella,
MenACWY, and MenB 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 route by which the vaccine was given as either intramuscular
(IM), subcutaneous (Subcut), intradermal (ID), intranasal (NAS), 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
documentation, a healthcare setting may want to keep a reference list of
vaccinators that includes their initials and titles.
Abbreviation
Trade Name and Manufacturer
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, Fluzone Intradermal, Fluzone
High-Dose (Sanofi Pasteur)
LAIV (live attenuated
influenza vaccine, quadrivalent]
FluMist (MedImmune)
PCV13
PPSV23
HZV (shingles)
Prevnar 13 (Pfizer)
Pneumovax 23 (Merck)
Zostavax (Merck)
Hib
ActHIB (Sanofi Pasteur); Hiberix (GSK); PedvaxHib
(Merck)
Immunization Action Coalition • Saint Paul, Minnesota • 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org
www.immunize.org/catg.d/p2023.pdf • Item #P2023 – page 2 (4/16)
Vaccine Administration Record
for Adults
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