Acip vaccine administration guidelines for immunization. Comvax vaccine administered vfc status manufacturerdate vaccine vaccine information vis vaccine administrator signature mmddyy patient age dosage route site c lot number expiration date date vis published. The location of all injection sites with the corresponding vaccine injected should be documented in each patients medical record. I acknowledge that riteaid intends to share my vaccination record with the california immunization registry cair. Vfcenrolled providers are required to document vfcpublicly funded vaccine eligibility for all children immunized at their practices. I also acknowledge that i have had a chance to ask questions and that such questions were answered to my satisfaction. Before administering any vaccines, give the patient copies of all pertinent vaccine information statements viss and make sure heshe understands the risks and benefits of the vaccine s. Georgia vaccine administration record vaccine circle statements place v in box c if combination vaccine given e. Parent, guardian or legal representative, or health care provider may provide vfc status information. This form is to be retained in accordance with the records retention and disposition schedule of medical records. Vaccine administration record var informed consent for vaccination healthcare providers can be a vaccinationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational. With the exception of hepatitis b vaccines, record the generic abbrevia tion e. Record the generic abbreviation for the type of vaccine given e.
Before administering any vaccines, give the parentguardian all appropriate copies of vaccine information statements vis. Vaccine administration record varinformed consent for. Record the funding source of the vaccine given as either f. Eligibility can be documented in paper form using the vaccine administration record pdf form or electronically in the providers electronic medical record. Vaccine administration record for children and teens state form 52642 406 immunization program instructions 1. Update the patients personal record card or provide a new one whenever you administer the vaccine. Parent, guardian, or vaccine recipient please read and initial. I understand the risks and benefits associated with the above vaccines and have received, read andor had explained to me the vaccine information statements on the vacciness i. Information may be shared through the wisconsin immunization registry wir. Vaccine administration record for adults pdf icon external icon. Record the funding source of the vaccine given as either f federal, s state, or p private. Fill out, securely sign, print or email your vaccine administration record var walgreens instantly with signnow. Inactive vaccine consent and administration record patient information.
Record the publication date of each vis as well as the date it is given to the patient. I understand the risks and benefits associated with the above vaccine s and have received, read andor had explained to me the vaccine information statements on the vacciness i have elected to receive. Visit the cdc vaccine administration website or the immunization action coalition for information and resources on administering vaccines. Georgia vaccine administration record vaccine circle place v in box c if combination vaccine given e. Protecting and promoting the health and safety of the people of wisconsin. Vaccine administration record var informed consent for vaccination for all health care providers ages 2 to 49 only section b the following questions will help us determine.
See page 2 to record meningococcal acwy, meningococcal b, influenza, and other vaccines e. Walgreens var form fill out and sign printable pdf. Vaccine administration record for children and teens. Comply with standards outlined in oregon administrative rule 333. Flu shot high dose flu shot preservative free flu shot pneumonia shingles tetanus other. Vaccine administration record for children and teens page 2 of 2 patient name. Last name first name mi nc department of health and.
I have read, or have had explained, the information about the diseases and the. Inactive vaccine consent and administration record. Vaccine administration record for children and teens pneumococcal e. Healthcare practices should consider using a vaccination site map so that all persons administering vaccines routinely use a particular anatomic site for each particular vaccine. Vaccine information statements viss and make sure heshe understands the risks and benefits of the vaccines. Before administering any vaccines, give the patient copies of all pertinent vaccine information statements viss and make sure heshe understands the risks and benefits of the vaccines. I have read, or have had explained, the information about the diseases and the vaccine s listed below. Prominently display vaccine records so they are easily found in the chart. Update the patients personal record card or provide a new one whenever you administer vaccine. There was an opportunity to ask questions and all questions were answered satisfactorily. Record the publication date of each vis as well as the date the vis is. Information collected on this form will be used to document authorization for receipt of vaccines. Vaccine administration record for adults chart number. Vaccine administration record var informed consent for vaccination for all health care providers ages 2 to 49 only section b the following questions will help us determine your eligibility to be vaccinated today.
Vaccine administration record wisconsin department of. Vaccine administration record for adults connecticare. Last name first name mi nc department of health and human. I understand that social security numbers are used to match immunization information received from multiple sources. Vaers table of reportable events following vaccinationpdf iconexternal icon. Health care providers who administer vaccines covered by the national childhood vaccine injury act are required to ensure that. Immunization forms washington state department of health. Update the patients personal record card or provide a new one whenever you administe r vaccine. Health care providers are required by law to record certain information in a patients medical record. Update the patients record with any new allergy, health condition or primary care provider information. For combination vaccines, fill in a row for each separate antigen in the combination. Update the patient record with any new allergy, health condition or primary care provider information.
Vaccine administration record for adults pdf icon external icon health care providers are required by law to record certain information in a patients medical record. I agree to allow the health care provider giving vaccinations to release information about all. Vaccination against smallpox number of previous vaccination scars date. Vaccine administration proper vaccine administration is critical to ensure that vaccination is safe and effective. Manufacturer and lot number date given administered by hepb 3 adult immunization record and history patient name last name, first name, middle initial. Proper vaccine administration is critical to ensure that vaccination is safe and effective. Vaccine administration record varinformed consent for vaccination healthcare providers can be a vaccinationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational. Vaccine administration record var informed consent for. Manufacturer and lot number date given administered by hepb 3 adult immunization record and history patient name last name, first name, middle initial number.
Vaccine administration record for adults see page 2 to record influenza, pneumococcal, zoster, hib, and other vaccines e. Vaccine administration record for adults pennsylvania. I acknowledge that riteaid intends to share my vaccination record with the california immunization registry cair and that i. With the recent change to our child care and school rules there is a slight change in. Vaccine administration record varinformed consent for vaccination.
I understand that refusing to provide my social security number will not affect. Vaccine administration record varinformed consent for vaccination healthcare providers can be a vaccinationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physician assistant. Nc department of health and human services division of public health immunization branch vaccine administration record 1. These are specific resources to assist in administering vaccines. Vaccine administration record for adults immunization action.
The aap bookstore has a vaccine administration record available for purchase. For more information about the 2019 novel coronavirus situation, please visit our covid19 page. A copy of the appropriate centers for disease control and prevention vaccine information statements has been provided. Always provide or update the patients personal record card. Childhoodadolescent immunization administration record.
When combination vaccines are given, enter the vaccine information in each separate vaccine row. Do not charge for the cost of a statesupplied vaccine. The most secure digital platform to get legally binding. Providing a social security number will help make sure my immunization record is accurate and uptodate and help prevent overuse of vaccines. Complete the vfc status column for every vaccination given to every child less than 19 years of age. I acknowledge that if my insurance does not cover the cost of administering the vaccine at the pharmacy, then payment must be made at the time of the administration of the vaccine. Sign in the signature column for each vaccine row below. Vaccine administration record for adults patient name. Eligibility can be documented in paper form using the vaccine administration record pdf. Vaccine administration record north dakota department of health. Cdc recommends that all health care personnel who administer vaccines receive comprehensive, competencybased training on vaccine administration policies and procedures before administering vaccines. Vaccine administration record var informed consent for vaccination healthcare providers can be a vaccinationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physicians assistant. Vaccine administration record var informed consent for vaccination healthcare providers can be an immunization certified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physicians assistant. Waive administration fees on statesupplied vaccine if a patient cannot pay.
1342 808 1126 1507 676 1582 652 47 1374 1340 831 1121 125 1404 1148 328 651 522 1563 574 580 1009 1108 959 907 430 1213 1130 1155 1032 572 1132 678 1309 1198 785 86 347 1378 1151 643 932 342 1318 883 1229 952