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
%LUWKGDWH&KDUWQXPEHU
%HIRUHDGPLQLVWHULQJDQ\YDFFLQHVJLYHFRSLHVRIDOOSHUWLQHQW9DFFLQH
,QIRUPDWLRQ6WDWHPHQWV9,6VWRWKHFKLOGôVSDUHQWRUOHJDOUHSUHVHQWDWLYH
DQGPDNHVXUHKHVKHXQGHUVWDQGVWKHULVNVDQGEHQHƫWVRIWKHYDFFLQHV
$OZD\VSURYLGHRUXSGDWHWKHSDWLHQWôVSHUVRQDOUHFRUGFDUG
Vaccine
Hepatitis B6
HJ+HS%+LE+HS%
'7D3+HS%,39
*LYH,07
Type of
Vaccine1
page 1 0f 2
Date vaccine Funding
Source
given
PRGD\\U )63
Site3
practice name and address
Metropolitan Pediatrics
6547 Grand Avenue
Big City, AB 35791
Vaccine Information
Statement (VIS)
Vaccine
/RW
0IU
Vaccinator5
'DWHRQ9,64
'DWHJLYHQ4
VLJQDWXUHRU
LQLWLDOVDQGWLWOH
HepB
6/2/2010
P
IM/RT
0651M
MRK
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
DLW
Diphtheria, Tetanus,
Pertussis6
HJ'7D3'7D3+LE
'7D3+HS%,39'7
'7D3,39+LE'7D3,39
7GDS7G*LYH,07
Pediarix
8/2/2010
F
IM/RT
GSK
5/17/07
8/2/2010
DCP
Pediarix
10/2/2010
635A1
F
IM/RT
712A2
GSK
5/17/07
10/2/2010
DCP
Pediarix
12/2/2010
F
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
F
IM/RA
376912
PMC
5/17/07
8/2/2015
JTA
+DHPRSKLOXVLQƬXHQ]DH
type b6
HJ+LE+LE+HS%
'7D3,39+LE'7D3+LE
+LE0HQ&<*LYH,07
Hib
8/2/2010
F
IM/RT
1492L
MSD
12/16/98
8/2/2010
DCP
Hib
10/2/2010
F
IM/RT
1492L
MSD
12/16/98
10/2/2010
DCP
Hib
12/2/2010
F
IM/RT
1492L
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
DCP
712A2
GSK
1/1/00
10/2/2010
DCP
Polio
HJ,39'7D3+HS%,39
'7D3,39+LE'7D3,39
*LYH,396XEFXWRU,07
*LYHDOORWKHUV,07
6
Pneumococcal
HJ3&93&9
FRQMXJDWH3369
SRO\VDFFKDULGH
*LYH3&9,07*LYH
33696XEFXW RU,07
Rotavirus5959
*LYHRUDOO\SR
Pediarix
8/2/2010
F
IM/RT
Pediarix
10/2/2010
F
IM/RT
Pediarix
12/2/2010
F
IM/RT
712A2
GSK
1/1/00
12/2/2010
DLW
IPV
8/2/2015
F
IM/LA
U4569-8
PMC
11/8/11
8/2/2015
RLV
PCV13
8/2/2010
F
IM/LT
7-5095-05A
WYE
4/16/10
8/2/2010
DCP
PCV13
10/2/2010
F
IM/LT
7-5095-05A
WYE
4/16/10
10/2/2010
DCP
PCV13
12/2/2010
F
IM/LT
7-5095-05A
WYE
4/16/10
12/2/2010
DLW
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
MSD
5/14/10
12/2/2010
DLW
See page 2WRUHFRUGPHDVOHVPXPSVUXEHOODYDULFHOODKHSDWLWLV$
PHQLQJRFRFFDO+39LQƬXHQ]DDQGRWKHUYDFFLQHVHJWUDYHOYDFFLQHV
How to Complete this Record
5HFRUGWKHJHQHULFDEEUHYLDWLRQHJ7GDSRUWKHWUDGHQDPHIRUHDFK
YDFFLQHVHHWDEOHDWULJKW
5HFRUGWKHIXQGLQJVRXUFHRIWKHYDFFLQHJLYHQDVHLWKHU)IHGHUDO
6VWDWHRU3SULYDWH
5HFRUGWKHVLWHZKHUHYDFFLQHZDVDGPLQLVWHUHGDVHLWKHU5$ULJKWDUP
/$OHIWDUP57ULJKWWKLJK/7OHIWWKLJKRU1$6LQWUDQDVDO
5HFRUGWKHSXEOLFDWLRQGDWHRIHDFK9,6DVZHOODVWKHGDWHWKH9,6LV
JLYHQWRWKHSDWLHQW
7RPHHWWKHVSDFHFRQVWUDLQWVRIWKLVIRUPDQGIHGHUDOUHTXLUHPHQWVIRU
GRFXPHQWDWLRQDKHDOWKFDUHVHWWLQJPD\ZDQWWRNHHSDUHIHUHQFHOLVWRI
YDFFLQDWRUVWKDWLQFOXGHVWKHLULQLWLDOVDQGWLWOHV
)RUFRPELQDWLRQYDFFLQHVƫOOLQDURZIRUHDFKDQWLJHQLQWKHFRPELQDWLRQ
,0LVWKHDEEUHYLDWLRQIRULQWUDPXVFXODU6XEFXWLVWKHDEEUHYLDWLRQIRU
VXEFXWDQHRXV
Abbreviation
Trade Name and Manufacturer
DTaP
'DSWDFHO6DQRƫ3DVWHXU,QIDQUL[*OD[R6PLWK.OLQH>*6.@
7ULSHGLD6DQRƫ3DVWHXU
*HQHULF6DQRƫ3DVWHXU
3HGLDUL[*6.
3HQWDFHO6DQRƫ3DVWHXU
.LQUL[*6.4XDGUDFHO6DQRƫ3DVWHXU
(QJHUL[%*6.5HFRPELYD[+%0HUFN
7ZLQUL[*6.FDQEHJLYHQWRWHHQVDJHDQGROGHU
$FW+,%6DQRƫ3DVWHXU+LEHUL[*6.3HGYD[+,%0HUFN
0HQ+LEUL[*6.
,SRO6DQRƫ3DVWHXU
3UHYQDU3ƫ]HU
3QHXPRYD[0HUFN
5RWDUL[*6.
5RWD7HT0HUFN
$GDFHO6DQRƫ3DVWHXU%RRVWUL[*6.
'HFDYDF7HQLYDF6DQRƫ3DVWHXU*HQHULF0$%LRORJLFDO/DEV
'7SHGLDWULF
'7D3+HS%,39
'7D3,39+LE
'7D3,39
HepB
HepA-HepB
+LE
+LE0HQ&<
,39
3&9
3369
59
59
7GDS
7G
THFKQLFDOFRQWHQWUHYLHZHGE\WKH&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ
Immunization Action Coalition
Saint Paul, Minnesota 651- 647- 9009 t www.immunize.org t www.vaccineinformation.org
t
ZZZLPPXQL]HRUJFDWJGpSGIt,WHP3 (4
Vaccine Administration Record
for Children and Teens FRQWLQXHG
6/1/2010
%LUWKGDWH&KDUWQXPEHU
%HIRUHDGPLQLVWHULQJDQ\YDFFLQHVJLYHFRSLHVRIDOOSHUWLQHQW9DFFLQH
,QIRUPDWLRQ6WDWHPHQWV9,6VWRWKHFKLOGôVSDUHQWRUOHJDOUHSUHVHQWDWLYH
DQGPDNHVXUHKHVKHXQGHUVWDQGVWKHULVNVDQGEHQHƫWVRIWKHYDFFLQHV
$OZD\VSURYLGHRUXSGDWHWKHSDWLHQWôVSHUVRQDOUHFRUGFDUG
Type of
Vaccine1
Date vaccine Funding
Source
given
PRGD\\U )63
Measles, Mumps, Rubella6
HJ0050059
*LYH6XEFXW7
MMRV
7/2/2011
F
MMRV
8/2/2015
F
Varicella6HJ9$5
0059*LYH6XEFXW7
MMRV
7/2/2011
MMRV
Vaccine
Hepatitis A +HS$
*LYH,07
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
Vaccinator5
/RW
0IU
'DWHRQ9,64
'DWHJLYHQ4
VLJQDWXUHRU
LQLWLDOVDQGWLWOH
Subcut/RA
0857M
MSD
5/21/10
7/2/2010
DLW
Subcut/LA
0522F
MSD
5/21/10
8/2/2015
DCP
F
Subcut/RA
0857M
MSD
5/21/10
7/2/2010
DLW
8/2/2015
F
Subcut/LA
05ssF
MSD
5/21/10
8/2/2015
DCP
Havrix
7/2/2011
F
IM/LA
AHAVB944
GSK
3/21/06
7/2/2010
DLW
Vaqta
1/5/2012
F
IM/LA
0634K
MSD
3/21/06
1/5/2011
TAA
Fluzone
12/2/2010
F
IM/LT
U097543
PMC
8/10/10
12/1/2010
DLW
Fluzone
1/5/2011
F
IM/LT
U097543
PMC
8/10/10
1/5/2011
JTA
IIV3
9/15/2011
F
IM/RT
U068954
PMC
7/26/11
9/15/2011
TAA
NAS
500491P
Meningococcal ACWY; CY
HJ0HQ$&:<>0&9@
+LE0HQ&<
*LYH0HQ$&:<DQG
+LE0HQ&<,07
Meningococcal BHJ
0HQ%*LYH0HQ%,07
Human papillomavirus
HJ+39+39
+39*LYH,07
,QƬXHQ]D HJ,,9,,9
FF,,95,9/$,9
*LYH,,9,,9FF,,9
DQG5,9,07
*LYH/$,91$6
7
LAIV3
9/2/2012
F
9/15/2013
F
NAS
65431P
Fluarix (IIV4) 10/1/2014
F
IM/RT
F
NAS
FluMist
LAIV4
9/10/2015
MED
7/2/2012 9/10/2012
RLV
MED 7/26/2013 9/15/2013
JTA
J5G53
GSK
8/19/2014 10/1/2014
DCP
78591P
MED
8/7/2015 9/10/2015
DLW
Other
See page 1WRUHFRUGKHSDWLWLV%GLSKWKHULDWHWDQXVSHUWXVVLVHaemophilus
LQƬXHQ]DHW\SHESROLRSQHXPRFRFFDODQGURWDYLUXVYDFFLQHV
How to Complete this Record
5HFRUGWKHJHQHULFDEEUHYLDWLRQHJ7GDSRUWKHWUDGHQDPHIRUHDFK
YDFFLQHVHHWDEOHDWULJKW
5HFRUGWKHIXQGLQJVRXUFHRIWKHYDFFLQHJLYHQDVHLWKHU)IHGHUDO
6VWDWHRU3SULYDWH
5HFRUGWKHVLWHZKHUHYDFFLQHZDVDGPLQLVWHUHGDVHLWKHU5$ULJKWDUP
/$OHIWDUP57ULJKWWKLJK/7OHIWWKLJKRU1$6LQWUDQDVDO
5HFRUGWKHSXEOLFDWLRQGDWHRIHDFK9,6DVZHOODVWKHGDWHWKH9,6LV
JLYHQWRWKHSDWLHQW
7RPHHWWKHVSDFHFRQVWUDLQWVRIWKLVIRUPDQGIHGHUDOUHTXLUHPHQWVIRU
GRFXPHQWDWLRQDKHDOWKFDUHVHWWLQJPD\ZDQWWRNHHSDUHIHUHQFHOLVWRI
YDFFLQDWRUVWKDWLQFOXGHVWKHLULQLWLDOVDQGWLWOHV
)RUFRPELQDWLRQYDFFLQHVƫOOLQDURZIRUHDFKDQWLJHQLQWKHFRPELQDWLRQ
,0LVWKHDEEUHYLDWLRQIRULQWUDPXVFXODU6XEFXWLVWKHDEEUHYLDWLRQIRU
VXEFXWDQHRXV
Abbreviation
Trade Name and Manufacturer
005
9$5
0059
HepA
HepA-HepB
+39
+39+39
005,,0HUFN
9DULYD[0HUFN
3UR4XDG0HUFN
+DYUL[*OD[R6PLWK.OLQH>*6.@9DTWD0HUFN
7ZLQUL[*6.
&HUYDUL[*6.
*DUGDVLO*DUGDVLO0HUFN
/$,9OLYHDWWHQXDWHGLQƬXHQ]DYDFFLQHTXDGULYDOHQW
)OX0LVW0HG,PPXQH
,,9LQDFWLYDWHGLQƬXHQ]DYDFFLQHWULYDOHQW,,9LQDFWLYDWHG
LQƬXHQ]DYDFFLQHTXDGULYDOHQW
FF,,9FHOOFXOWXUHEDVHG
LQDFWLYDWHGLQƬXHQ]DYDFFLQH
WULYDOHQW5,9LQDFWLYDWHG
UHFRPELQDQWLQƬXHQ]DYDFFLQH
WULYDOHQW
)OXDUL[*6.)OXEORN3URWHLQ6FLHQFHV&RUS
$ƬXULD)OXDG)OXFHOYD[)OXYLULQ6HTLUXV
)OX/DYDO*6.)OX]RQH6DQRƫ3DVWHXU
0HQ$&:<
+LE0HQ&<
0HQ%
0HQDFWUD6DQRƫ3DVWHXU0HQYHR*6.
0HQ+LEUL[*6.
%H[VHUR*6.7UXPHQED3ƫ]HU
Immunization Action Coalition t Saint Paul, Minnesota t 651- 647- 9009 t www.immunize.org t www.vaccineinformation.org
ZZZLPPXQL]HRUJFDWJGpSGIt,WHP3ñSDJH (4