Vaccine Administration Re.
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fore administering any vaccines, give copies of all per - ; - 7
Information Statements (Iss) toed or ga represen ponves Aude
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Meningococcal 8 (og,
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HPV9) Give IM? |
Influenza (e.g. V3, V4,
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Give 1¥3,t1v4, ettv3, : —
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Give LAIV4 NAS.”
D> See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Hoemephils
influenzae type b, polio, preumococcal, and rotavirus vaccines.
How to Complete this Record
1. Record the generic abbreviation (e.g, Tdap) or the trade name foreach
vaccine (se table at right)
Record the funding source ofthe vaccine given as either F (federal),
S (state), orP (private).
Record the site where vaccine was administered a ether RA (cight ar),
LA (left arm), RT (right thigh), LT (left thigh), or NAS (intranasal)
4. Record the publication date ofeach VIS as well as the date the VIS is
given tothe patient.
Foret the space constraints of ths form and federal requirements for
documentation, a healthcare setting may want to keep a reference list of
vaccinators that includes their initials and tes.
6. For combination vaccines lina row foreach antigen inthe combination
71M is the abbreviation for intramuscular, Subcut is the abbreviation for
subcutaneous.
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Immunization Action Coalition « Saint Paul, Minnesota = 651-647-9009 + www.immunize.org « www.vaccineinformation.org
‘ww immunize org/eatg.¢/p 2022 pd «Item P2022 ~ page 2 (4/16)