Vaccine Administration Record
for Adults
(Page 1 of 2)
Patient name:
Birthdate: Chart number:
Clinic name and address
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 patients personal record card.
Vaccine
Tetanus,
Diphtheria, Pertussis
(e.g., Td, Tdap)
Give IM.3
Type of Vaccine1 Date given
(mo/day/yr)
Funding Route3
source & Site3
(F,S,P)2
Vaccine Information
Statement (VIS)
Vaccine
Lot #
Mfr.
Date on VIS4
Date given4
Vaccinator5
(signature or
initials & title)
Hepatitis A6
(e.g., HepA, HepA-HepB)
Give IM.3
Hepatitis B6
(e.g., HepB, HepA-HepB)
Give IM.3
Human papillomavirus
(HPV2, HPV4)
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
See page 2 to record influenza, Hib, zoster, and other vaccines (e.g., travel vaccines).
How to Complete This Record
Abbreviation
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 (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.
Tdap
Td
HepA
HepB
HepA-HepB
HPV2
HPV4
MMR
VAR
PCV13, PPSV23
MenACWY
MPSV4
Trade Name and Manufacturer
Adacel (sanofi pasteur); Boostrix (GlaxoSmithKline [GSK])
Decavac (sanofi pasteur); generic Td (MA Biological Labs)
Havrix (GSK); Vaqta (Merck)
Engerix-B (GSK); Recombivax HB (Merck)
Twinrix (GSK)
Cervarix (GSK)
Gardasil (Merck)
MMRII (Merck)
Varivax (Merck)
Prevnar 13 (Pfizer); Pneumovax 23 (Merck)
Menactra (sanofi pasteur); Menveo (Novartis)
Menomune (sanofi pasteur)
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.
Technical content reviewed by the Centers for Disease Control and Prevention
For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (4/14)
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
Vaccine Administration Record
for Adults
(Page 2 of 2)
Patient name:
Birthdate: Chart number:
Clinic name and address
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 patients personal record card.
Vaccine
Type of Vaccine1
Influenza
(e.g., IIV3, trivalent
inactivated;
IIV4, quadrivalent inactivated;
RIV, recombinant inactivated;
LAIV4, quadrivalent live
attenuated)
Give IIV and RIV IM.3
Give LAIV IN.3
Funding
Route3
Source
(mo/day/yr)
& Site3
(F,S,P)2
Date given
Vaccine Information
Statement (VIS)
Vaccine
Lot #
Mfr.
Date on VIS4
Date given4
Vaccinator5
(signature or
initials & title)
Hib Give IM.3
Zoster (Zos) Give SC.
Other
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal 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 (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).
Abbreviation
Trade Name and Manufacturer
LAIV (Live attenuated
influenza vaccine]
FluMist (MedImmune)
IIV (Inactivated influenza vaccine), RIV
(recombinant influenza
vaccine)
Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK);
Flublok (Protein Sciences Corp.); Flucelvax (Novartis); FluLaval
(GSK); Fluvirin (Novartis); Fluzone, Fluzone Intradermal, Fluzone
High-Dose (sanofi pasteur)
Hib
ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHib (Merck)
ZOS (shingles)
Zostavax (Merck)
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.
Technical content reviewed by the Centers for Disease Control and Prevention
For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (4/14)
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
(Page 1 of 2)
Patient name: Mohammed Sharik
4/14/1981
Birthdate: Chart
number:
Vaccine Administration Record
for Adults
Clinic name and address Small Town Clinic
1st and Main Streets
Anywhere, AB 12345
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 patients personal record card.
Type of Vaccine1 Date given
Vaccine
Tetanus,
Diphtheria, Pertussis
(e.g., Td, Tdap)
Give IM.3
(mo/day/yr)
Funding Route3
source & Site3
(F,S,P)2
Vaccine Information
Statement (VIS)
Vaccine
Lot #
Mfr.
Date on VIS4
Date given4
Vaccinator5
(signature or
initials & title)
Td
8/1/2002 P IM/LA U0376AA
AVP 6/10/94 8/1/02
JTA
Td
9/1/2002 P IM/LA U0376AA
AVP 6/10/o4 9/1/02
PWS
Td
3/1/2003 P IM/LA U0376AA
AVP 6/10/94 3/1/03
TAA
Tdap
6/14/2010
IM/LA
AC52B030AA GSK
6/14/10
6/14/10
JTA
HepA-HepB
8/1/2002 P IM/RA HAB239A4 GSK 8/25/98 8/1/02
JTA
HepA-HepB
9/1/2002 P IM/RA HAB239A4 GSK 8/25/98 9/1/02
PWS
HepA-HepB
3/1/2003 P IM/RA HAB239A4 GSK 8/25/98 3/1/03
TAA
Hepatitis B
HepA-HepB
(e.g., HepB, HepA-HepB)
HepA-HepB
Give IM.3
9/1/2002 P IM/RA HAB239A4 GSK 7/11/01 9/1/02
PWS
TAA
IM/RA HAB239A4 GSK 7/11/01 8/1/02
HepA-HepB
3/1/2003 P IM/RA HAB239A4 GSK 7/11/01 3/1/03
MMR
8/1/2002 P
MMR
VAR
VAR
Pneumococcal
(e.g., PCV13, conjugate;
PPSV23, polysaccharide)
Give PCV13 IM.3
Give PPSV23 IM or SC.3
8/1/2002 P
11/1/2002
MRK 6/13/02 8/1/02
SC/RA
MRK 6/13/02
0025L
11/1/02
JTA
TAA
SC/LA 0799M
MRK 12/16/98 8/1/02
JTA
SC/LA
MRK 12/16/98
TAA
0689M
7/12/2010 P IM/RA 28011
11/1/02
NOV 1/2/8/08 7/12/10
Ex
Menveo
Meningococcal
(e.g., MenACWY, conjugate;
MPSV4, polysaccharide)
Give MenACWY IM.3
Give MPSV4 SC.3
11/1/2002
SC/RA 0025L
am
JTA
Human papillomavirus
(HPV2, HPV4)
Give IM.3
Measles, Mumps,
Rubella
(MMR) Give SC.3
Varicella
(VAR) Give SC.3
8/1/2002 P
pl
Hepatitis A6
(e.g., HepA, HepA-HepB)
Give IM.3
JTA
See page 2 to record influenza, Hib, zoster, and other vaccines (e.g., travel vaccines).
How to Complete This Record
Abbreviation
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 (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.
Tdap
Td
HepA
HepB
HepA-HepB
HPV2
HPV4
MMR
VAR
PCV13, PPSV23
MenACWY
MPSV4
Trade Name and Manufacturer
Adacel (sanofi pasteur); Boostrix (GlaxoSmithKline [GSK])
Decavac (sanofi pasteur); generic Td (MA Biological Labs)
Havrix (GSK); Vaqta (Merck)
Engerix-B (GSK); Recombivax HB (Merck)
Twinrix (GSK)
Cervarix (GSK)
Gardasil (Merck)
MMRII (Merck)
Varivax (Merck)
Prevnar 13 (Pfizer); Pneumovax 23 (Merck)
Menactra (sanofi pasteur); Menveo (Novartis)
Menomune (sanofi pasteur)
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.
Technical content reviewed by the Centers for Disease Control and Prevention
For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (4/14)
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
Vaccine Administration Record
for Adults
(Page 2 of 2)
Patient name: Mohammed Sharik
4/14/1981
Birthdate: Chart
number:
Clinic name and address Small Town Clinic
1st and Main Streets
Anywhere, AB 12345
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 patients personal record card.
Vaccine
Date given
(mo/day/yr)
Funding
Route3
Source
& Site3
(F,S,P)2
Mfr.
Date on VIS4
Date given4
(signature or
initials & title)
11/1/2002
IM/RA U088211
AVP
6/26/02
11/1/02
PWS
TIV
10/10/2003
IM/LA
U091145
AVP
5/6/03
10/10/03
DLW
10/8/2004
IM/RA U100461
AVP
5/24/04
10/8/04
TAA
12/12/2005
IM/LA
SPI
7/18/05
12/12/05
JTA
Fluzone
TIV
Fluvirin
10/9/2006 P
U2169MA
IM/LA 878771P
11/15/07
MED
7/6/07
11/15/07
DCP
10/12/2008
IM/RA 06949111A
CSL
7/24/08
10/12/08
JTA
Flulaval
10/12/2009
IM/LA
GSK
8/11/09
10/2/09
DCP
TIV
RIV
500337P
KKC
Afluria
Fluzone ID
IN
NOV 6/30/06 10/9/06
FluMist
Fluarix
2F600411
12/7/2009 P IM/RA 1009224P
NOV 10/2/09 12/7/09
DLW
9/9/2010
IM/LA
J5G53
GSK
8/10/10
9/9/10
JRM
10/10/2011
ID/LA
UT4720BA
PMC
7/26/11
10/10/11
CJP
IM/RA M50907
CSL 7/2/12
IM/RA 350603F
9/5/2012
12/12/2013
PSC
9/5/12
DLW
7/26/13
12/12/13
JRM
5/29/12
7/12/12
MAT
Zoster (Zos) Give SC.3
7/12/12x4
PO
TXE355
Ex
Oral typhoid
am
pl
Other
Lot #
Vaccinator5
TIV
H1N1
Hib Give IM.3
Vaccine Information
Statement (VIS)
Vaccine
Influenza
(e.g., IIV3, trivalent
inactivated;
IIV4, quadrivalent inactivated;
RIV, recombinant inactivated;
LAIV4, quadrivalent live
attenuated)
Give IIV and RIV IM.3
Give LAIV IN.3
Type of Vaccine1
BER
See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal 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 (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).
Abbreviation
Trade Name and Manufacturer
LAIV (Live attenuated
influenza vaccine]
FluMist (MedImmune)
IIV (Inactivated influenza vaccine), RIV
(recombinant influenza
vaccine)
Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK);
Flublok (Protein Sciences Corp.); Flucelvax (Novartis); FluLaval
(GSK); Fluvirin (Novartis); Fluzone, Fluzone Intradermal, Fluzone
High-Dose (sanofi pasteur)
Hib
ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHib (Merck)
ZOS (shingles)
Zostavax (Merck)
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.
Technical content reviewed by the Centers for Disease Control and Prevention
For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (4/14)
This form was created by the Immunization Action Coalition www.immunize.org www.vaccineinformation.org
