Vaccine Administration Record for Adults



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(Page 1 of 2) Administration Record for Adults Birthdate: Before administering any vaccines, give the patient copies of all pertinent 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. 1 source Information Vaccinator 5 Lot # Mfr. Date on VIS 4 4 Tetanus, Diphtheria, Pertussis (e.g., Td, Tdap) Hepatitis A 7 (e.g., HepA, ) Hepatitis B 7 (e.g., HepB, ) Human papillomavirus (HPV2, HPV4) Measles, Mumps, Rubella (MMR) Give SC. 6 Varicella (VAR) Give SC. 6 Pneumococcal polysaccharide (PPSV23) Give SC or IM. 6 Meningococcal (e.g., MCV4, conjugate; MPSV4, polysaccharide) Give MCV4 IM. 6 Give MPSV4 SC. 6 See page 2 to record influenza, zoster, and other vaccines (e.g., travel vaccines). 6. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. 7. For combination vaccines, fill in a row for each antigen in the combination. Tdap Td HepA HepB HPV2 HPV4 MMR VAR PPSV23 MCV4 MPSV4 Adacel (sanofi pasteur), Boostrix (GlaxoSmithKline [GSK]) Decavac (sanofi pasteur), generic (MA Biological Labs) Havrix (GSK); Vaqta (Merck) Engerix-B (GSK), Recombivax HB (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) MMRII (Merck) Varivax (Merck) Pneumovax 23 (Merck) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur) For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (3/11)

(Page 2 of 2) Administration Record for Adults Birthdate: Before administering any vaccines, give the patient copies of all pertinent 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. 1 Information Vaccinator 5 Lot # Mfr. Date on VIS 4 4 Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. 6 Give LAIV IN. 6 Zoster (ZOS) Give SC. 6 Other See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal vaccines. LA (left arm), RT (right thigh), LT (left thigh), IN (intranasal), or. 6. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal. LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) ZOS (shingles) FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi pasteur); Fluzone High-Dose (sanofi pasteur) Zostavax (Merck) For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (3/11)

(Page 1 of 2) Administration Record for Adults Mohammed Sharik Birthdate: 4/14/1981 Before administering any vaccines, give the patient copies of all pertinent 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. 1 Tetanus, Diphtheria, Pertussis (e.g., Td, Tdap) source Information Vaccinator 5 Lot # Mfr. Date on VIS 4 4 Td 8/01/02 P LA U0376AA AVP 6/10/94 8/1/2002 JTA Td 9/1/2002 P LA U0376AA AVP 6/10/94 9/1/2002 PWS Td 3/1/2003 P LA U0376AA AVP 6/10/94 3/1/2003 TAA Tdap 6/14/2010 P LA AC52B030AA GSK 11/18/2008 6/14/2010 JTA Hepatitis A 7 (e.g., HepA, ) Hepatitis B 7 (e.g., HepB, ) Human papillomavirus (HPV2, HPV4) 8/1/2002 P RA HAB239A4 GSK 8/25/1998 8/1/2002 JTA 9/1/2002 P RA HAB239A4 GSK 8/25/1998 9/1/2002 PWS 3/1/2003 P RA HAB239A4 GSK 8/25/1998 3/1/2003 TAA 8/1/2002 P RA HAB239A4 GSK 7/11/2001 8/1/2002 JTA 9/1/2002 P RA HAB239A4 GSK 7/11/2001 9/1/2002 PWS 3/1/2003 P RA HAB239A4 GSK 7/11/2001 3/1/2003 TAA 1 shot, 2 different VIS dates Measles, Mumps, Rubella (MMR) Give SC. 6 Varicella (VAR) Give SC. 6 Pneumococcal polysaccharide (PPSV23) Give SC or IM. 6 Meningococcal (e.g., MCV4, conjugate; MPSV4, polysaccharide) Give MCV4 IM. 6 Give MPSV4 SC. 6 MMR 8/1/2002 P RA 0025L MRK 6/13/2002 8/1/2002 JTA MMR 11/1/2002 P RA 0025L MRK 6/13/2002 11/1/2002 TAA VAR 8/1/2002 P LA 0799M MRK 12/16/1998 8/1/2002 JTA VAR 11/1/2002 P RA 0689M MRK 12/16/1998 11/1/2002 TAA Menveo 7/12/2010 P RA 28011 NOV 1/28/2008 7/12/2010 JTA See page 2 to record influenza, zoster, and other vaccines (e.g., travel vaccines). 6. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. 7. For combination vaccines, fill in a row for each antigen in the combination. Tdap Td HepA HepB HPV2 HPV4 MMR VAR PPSV23 MCV4 MPSV4 Adacel (sanofi pasteur), Boostrix (GlaxoSmithKline [GSK]) Decavac (sanofi pasteur), generic (MA Biological Labs) Havrix (GSK); Vaqta (Merck) Engerix-B (GSK), Recombivax HB (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) MMRII (Merck) Varivax (Merck) Pneumovax 23 (Merck) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur) This is a record for a 29-year-old healthcare worker who is planning to travel to Saudi Arabia for the annual Hajj. For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (3/11)

Administration Record for Adults Mohammed Sharik Birthdate: 4/14/1981 (Page 2 of 2) Before administering any vaccines, give the patient copies of all pertinent 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. 1 Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. 6 Give LAIV IN. 6 Includes space to record vaccines given for international travel. Information Vaccinator 5 Lot # Mfr. Date on VIS 4 4 TIV 11/1/2002 P RA U088211 AVP 6/26/2002 11/1/2002 PWS TIV 10/10/2003 P LA U091145 AVP 5/6/2003 10/10/2003 DLW Fluzone 10/8/2004 P RA U100461 AVP 5/24/2004 10/8/2004 TAA TIV 11/12/2005 P LA U2169MA SPI 7/18/2005 11/12/2005 JTA Fluvirin 10/9/2006 P LA 878771P NOV 6/30/2006 10/9/2006 KKC Flumist 11/15/2007 P IN 500337P MED 7/16/2007 11/15/2007 DCP Afluria 10/12/2008 P RA 06949111A CSL 7/24/2008 10/12/2008 JTA Flulaval 10/2/2009 P LA 2F600411 GSK 8/11/2009 10/2/2009 DCP H1N1 12/7/2009 F RA 1009224P NOV 10/2/2009 12/7/2009 DLW Zoster (ZOS) Give SC. 6 Other Oral typhoid 7/12/2010 x 4 P po TXE355 BER 5/19/2004 7/12/2010 MAT See page 1 to record Tdap/Td, hepatitis A, hepatitis B, HPV, MMR, varicella, pneumococcal, and meningococcal vaccines. 6. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal. LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) ZOS (shingles) FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi pasteur); Fluzone High-Dose (sanofi pasteur) Zostavax (Merck) This is a record for a 29-year-old healthcare worker who is planning to travel to Saudi Arabia for the annual Hajj. For additional copies, visit www.immunize.org/catg.d/p2023.pdf Item #P2023 (3/11)

Administration Record Birthdate: (Page 1 of 2) Before administering any vaccines, give copies of all pertinent Information Statements (VISs) to the child s parent or legal representative 1 Information Lot # Mfr. Date on VIS 4 4 Hepatitis B 6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Diphtheria, Tetanus, Pertussis 6 (e.g., DTaP, DTaP/Hib, DTaP-HepB-IPV, DT, DTaP-IPV/Hib, Tdap, DTaP-IPV, Td) Haemophilus influenzae type b 6 (e.g., Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib) Polio 6 (e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV) Give IPV SC or IM. 7 Give all others IM. 7 Pneumococcal (e.g., PCV7, PCV13, conjugate; PPSV23, polysaccharide) Give PCV IM. 7 Give PPSV SC 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). How to Complete This Record 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine 2. Record the funding source of the vaccine given as either F (federal), S (state), 4. Record the publication date of each VIS as well as the date the VIS is given 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. DTaP DT (pediatric) DTaP-HepB-IPV DTaP/Hib DTaP-IPV/Hib DTaP-IPV HepB Hib Hib-HepB IPV PCV13 PPSV23 RV1 RV5 Tdap Td Daptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur) Generic (sanofi pasteur) Pediarix (GSK) TriHIBit (sanofi pasteur) Pentacel (sanofi pasteur) Kinrix (GSK) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck) Comvax (Merck) Ipol (sanofi pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (sanofi pasteur); Boostrix (GSK) Decavac (sanofi pasteur), Generic (MA Biological Labs)

Administration Record Birthdate: (Page 2 of 2) Before administering any vaccines, give copies of all pertinent Information Statements (VISs) to the child s parent or legal representative 1 Information Lot # Mfr. Date on VIS 4 4 Measles, Mumps, Rubella 6 (e.g., MMR, Varicella 6 (e.g., VAR, Hepatitis A (HepA) Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM 7 and MPSV4 SC. 7 Human papillomavirus (e.g., HPV2, HPV4) Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. 7 Give LAIV IN. 7 Other See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus vaccines. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal. MMR VAR MMRV HepA HPV2 HPV4 LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) MCV4 MPSV4 MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

Administration Record Emily Jacobs Birthdate: 6/2/2005 (Page 1 of 2) Before administering any vaccines, give copies of all pertinent Information Statements (VISs) to the child s parent or legal representative Hepatitis B 6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) DTaP-HepB-IPV (Pediarix) Diphtheria, Tetanus, Pertussis 6 (e.g., DTaP, DTaP/Hib, DTaP-HepB-IPV, DT, DTaP-IPV/Hib, Tdap, DTaP-IPV, Td) Haemophilus influenzae type b 6 (e.g., Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib) Polio 6 (e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV) Give IPV SC or IM. 7 Give all others IM. 7 Pneumococcal (e.g., PCV7, PCV13, conjugate; PPSV23, polysaccharide) Give PCV IM. 7 Give PPSV SC or IM. 7 Rotavirus (RV1, RV5) Give orally (po). 1 HepB 6/2/2005 F RT 0651M MRK 7/11/01 6/2/05 JTA Pediarix 8/2/2005 F RT 635A1 GSK 7/11/01 8/2/05 DCP Pediarix 10/2/2005 F RT 712A2 GSK 7/11/01 10/2/05 DCP Pediarix 12/2/2005 F RT 712A2 GSK 7/11/01 12/2/05 DLW Pediarix 8/2/2005 F RT 635A2 GSK 7/30/01 8/2/05 DCP Pediarix 10/2/2005 F RT 712A2 GSK 7/30/01 10/2/05 DCP Pediarix 12/2/2005 F RT 712A2 GSK 7/30/01 12/2/05 DLW DTaP-Hib 9/2/2006 F RA P0897AA SPI 7/30/01 9/2/06 RLV DTaP 8/2/2010 F RA 326-912 SPI 5/17/07 8/2/10 JTA Hib 8/2/2005 F LT UA744AA SPI 12/16/98 8/2/05 DCP Hib 10/2/2005 F LT UA744AA SPI 12/16/98 10/2/05 DCP Hib 12/2/2005 F LT UA744AA SPI 12/16/98 12/2/05 DLW DTaP-Hib 9/2/2006 F RA 7172AA SPI 12/16/98 9/2/06 RLV Pediarix 8/2/2005 F RT 635A2 GSK 1/1/00 8/2/05 DCP Pediarix 10/2/2005 F RT 712A2 GSK 1/1/00 10/2/05 DCP Pediarix 12/2/2005 F RT 712A2 GSK 1/1/00 12/2/05 DLW IPV 8/2/2010 F RA U4569-8 SPI 1/1/00 8/2/10 DCP PCV7 8/2/2005 F LT 489-835 WYE 9/30/02 8/2/05 DCP PCV7 10/2/2005 F RT 489-835 WYE 9/30/02 10/2/05 DCP PCV7 12/2/2005 F LT 489-835 WYE 9/30/02 12/2/05 DLW PCV7 9/2/2006 F LA 501-245 WYE 9/30/02 9/2/06 RLV PCV13 8/2/2010 F LA E44433 PFI 12/9/08 8/2/10 DCP DTaP DT (pediatric) DTaP-HepB-IPV DTaP/Hib DTaP-IPV/Hib DTaP-IPV HepB Hib Hib-HepB IPV PCV13 PPSV23 RV1 RV5 Tdap Td Information Lot # Mfr. Date on VIS 4 4 See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, and other vaccines (e.g., travel vaccines). How to Complete This Record 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine 2. Record the funding source of the vaccine given as either F (federal), S (state), 4. Record the publication date of each VIS as well as the date the VIS is given 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. DTaP-Hib (TriHIBit): 2 lot #s, 2 different VISs Pediarix: 3 different VIS dates Daptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur) Generic (sanofi pasteur) Pediarix (GSK) TriHIBit (sanofi pasteur) Pentacel (sanofi pasteur) Kinrix (GSK) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck) Comvax (Merck) Ipol (sanofi pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (sanofi pasteur); Boostrix (GSK) Decavac (sanofi pasteur), Generic (MA Biological Labs)

Administration Record Emily Jacobs Birthdate: 6/2/2005 (Page 2 of 2) Before administering any vaccines, give copies of all pertinent Information Statements (VISs) to the child s parent or legal representative Measles, Mumps, Rubella 6 (e.g., MMR, Varicella 6 (e.g., VAR, Hepatitis A (HepA) Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM 7 and MPSV4 SC. 7 Human papillomavirus (e.g., HPV2, HPV4) Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. 7 Give LAIV IN. 7 1 Information MMRV 6/2/2006 P RA 0857M MRK 1/15/03 6/2/06 DLW MMRV 8/2/2010 P LA 0522F MRK 5/21/10 8/2/10 DCP MMRV 6/2/2006 P RA 0857M MRK 12/16/98 6/2/06 DLW MMRV 8/2/2010 P LA 0522F MRK 5/21/10 8/2/10 DCP HepA 6/2/2006 P LA 0524L MRK 8/4/04 6/2/06 DLW HepA 12/2/2006 P LA 0634K MRK 3/21/06 8/2/06 MAT MMR-VAR (MMRV) Lot # Mfr. Date on VIS 4 4 TIV 12/5/2005 F RT U097543 SPI 7/18/05 12/5/05 JTA TIV 1/5/2006 F RT U097543 SPI 7/18/05 1/5/06 DCP TIV 10/16/2006 F LA U106459 SPI 6/30/06 10/16/06 MAT LAIV 11/15/2007 S IN 500337P MED 7/16/07 11/15/07 ABB TIV 10/12/2008 S RA U2169MA SPI 7/24/08 10/12/08 CAS TIV 10/2/2009 F LA 71211 NOV 8/11/09 10/2/09 MAT TIV-H1N1 11/15/2009 F RA UP016AA SPI 10/2/09 11/15/09 CEL LAIV-H1N1 12/29/2009 F IN 500756P MED 10/2/09 12/29/09 ZAZ Other See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus vaccines. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal. MMR VAR MMRV HepA HPV2 HPV4 LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) MCV4 MPSV4 MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

Administration Record Jessica Ashley Birthdate: 10/15/1991 (Page 1 of 2) Before administering any vaccines, give copies of all pertinent Information Statements (VISs) to the child s parent or legal representative Hepatitis B 6 (e.g., HepB, Hib-HepB, DTaP-HepB-IPV) Diphtheria, Tetanus, Pertussis 6 (e.g., DTaP, DTaP/Hib, DTaP-HepB-IPV, DT, DTaP-IPV/Hib, Tdap, DTaP-IPV, Td) Haemophilus influenzae type b 6 (e.g., Hib, Hib-HepB, DTaP-IPV/Hib, DTaP/Hib) Polio 6 (e.g., IPV, DTaP-HepB-IPV, DTaP-IPV/Hib, DTaP-IPV) Give IPV SC or IM. 7 Give all others IM. 7 Pneumococcal (e.g., PCV7, PCV13, conjugate; PPSV23, polysaccharide) Give PCV IM. 7 Give PPSV SC or IM. 7 Rotavirus (RV1, RV5) Give orally (po). 1 HepB (1.0 ml) 6/2/2004 P RA 0651M MRK 7/11/01 6/2/04 TAA HepB (1.0 ml) 1/2/2005 P RA 0651M MRK 7/11/01 1/2/05 TAA 2-dose series of adult Recombivax given to child 12-15 yrs Information Lot # Mfr. Date on VIS 4 4 DTP 12/15/1991 P RT 326-912 LED 1/1/88 12/15/91 DCP DTP 2/15/1992 P RT 326-912 LED 10/15/91 2/15/92 DCP DTaP 4/15/1992 P RT 326-912 LED 3/25/92 4/15/92 DLW DTaP 4/15/1993 P RA 326-912 LED 3/25/92 4/15/93 RLV DTaP 4/15/1996 P RA 657-888 LED 6/10/94 4/15/96 JTA Td 10/15/2003 P RA 467-854 LED 7/30/01 10/15/03 PWS Tdap 6/12/2010 P RA AC52B023AA GSK 11/18/08 6/12/10 DLW Hib 12/15/1991 P LT 1492L MRK 6/6/91 12/15/91 DCP PedvaxHIB 2/15/1992 P LT 1492L MRK 6/6/91 2/15/92 DCP Hib 10/15/1992 P LT 1492L MRK 6/6/91 10/15/92 DLW OPV 12/15/1991 P po 0678A LED 10/15/91 12/15/91 DCP OPV 2/15/1992 P po 0678A LED 10/15/91 2/15/92 DCP OPV 4/15/1993 P po 0678A LED 10/15/91 4/15/93 RLV OPV 4/15/1996 P po 0987A LED 10/15/91 4/15/93 JTA See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, and other vaccines (e.g., travel vaccines). How to Complete This Record 1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine 2. Record the funding source of the vaccine given as either F (federal), S (state), 4. Record the publication date of each VIS as well as the date the VIS is given 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous. DTaP DT (pediatric) DTaP-HepB-IPV DTaP/Hib DTaP-IPV/Hib DTaP-IPV HepB Hib Hib-HepB IPV PCV13 PPSV23 RV1 RV5 Tdap Td Daptacel (sanofi); Infanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur) Generic (sanofi pasteur) Pediarix (GSK) TriHIBit (sanofi pasteur) Pentacel (sanofi pasteur) Kinrix (GSK) Engerix-B (GSK); Recombivax HB (Merck) Twinrix (GSK); can be given to teens age 18 and older ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck) Comvax (Merck) Ipol (sanofi pasteur) Prevnar 13 (Pfizer) Pneumovax 23 (Merck) Rotarix (GSK) RotaTeq (Merck) Adacel (sanofi pasteur); Boostrix (GSK) Decavac (sanofi pasteur), Generic (MA Biological Labs)

Administration Record Jessica Ashley Birthdate: 10/15/1991 (Page 2 of 2) Before administering any vaccines, give copies of all pertinent Information Statements (VISs) to the child s parent or legal representative Measles, Mumps, Rubella 6 (e.g., MMR, Varicella 6 (e.g., VAR, Hepatitis A (HepA) 1 Information Lot # Mfr. Date on VIS 4 4 MMR 1/15/1993 P RA 0857M MRK 10/15/91 1/15/93 DLW MMR 10/15/2003 P LA 0946M MRK 1/15/03 10/15/03 PWS VAR 10/15/2003 P LA 0799M MRK 12/16/98 10/15/03 PWS VAR 10/15/2007 P LA 0689M MRK 1/10/07 10/15/07 JTA Meningococcal (e.g., MCV4; MPSV4) Give MCV4 IM 7 and MPSV4 SC. 7 Human papillomavirus (e.g., HPV2, HPV4) Influenza (e.g., TIV, inactivated; LAIV, live attenuated) Give TIV IM. 7 Give LAIV IN. 7 MCV4 6/12/2010 P LA 28011 NOV 1//28/08 6/12/10 MAT HPV2 12/12/2009 P LA 0331Z GSK 2/2/07 12/12/09 TAA Cervarix 2/13/2010 P LA 0331Z GSK 2/2/07 2/13/10 PWS Garadasil 6/12/2010 P LA 0637F MRK 2/2/07 6/12/10 DLW FluMist 10/15/2007 P IN 500491P MED 10/4/07 10/15/07 MAT TIV 10/12/2008 P RA 878771P NOV 7/24/08 10/12/08 JTA Fluzone 10/2/2009 P RA U100461 SPI 8/11/09 10/2/09 DLW H1N1 12/7/2009 P LA 1009224P NOV 10/2/09 12/7/09 MAT Other When recording the type of vaccine, use the generic abbreviation, tradename, or both. By recording the manufacturer, you will always be able to determine the brand of vaccine given. See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophilus influenzae type b, polio, pneumococcal, and rotavirus vaccines. 7. IM is the abbreviation for intramuscular; SC is the abbreviation for subcutaneous; IN is the abbreviation for intranasal. MMR VAR MMRV HepA HPV2 HPV4 LAIV (Live attenuated influenza vaccine] TIV (Trivalent inactivated influenza vaccine) MCV4 MPSV4 MMRII (Merck) Varivax (Merck) ProQuad (Merck) Havrix (GlaxoSmithKline [GSK]); Vaqta (Merck) Twinrix (GSK) Cervarix (GSK) Gardasil (Merck) FluMist (MedImmune) Afluria (CSL Biotherapies); Agriflu (Novartis); Fluarix (GSK); FluLaval (GSK); Fluvirin (Novartis); Fluzone (sanofi) Menactra (sanofi pasteur); Menveo (Novartis) Menomune (sanofi pasteur)

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