Forms include fields to record the following information for 12 different immunizations. Date given mdyy administered by clinic, doctor, etc. If vaccine recipient is under 18 years of age, fill out the shaded section. I believe i understand the benefits and risks of the. Record the site where vaccine was administered as either ra right arm. Always provide or update the patients personal record card. Dph05024h form 25imm002e georgia vaccine administration record. Health care providers are required by law to record certain information in a patients medical record.
Vaccine administration record for the person getting immunizations please print. Before administering vaccine, provide the patient or legal representative with the appropriate vis for each dose of vaccine given. I understand that the information contained on this form may be. For combination vaccines, fill in a row for each separate antigen in the combination. Vaccine administration record sfn 18385 082015 provider id. I have had a chance to ask questions that were answered to my satisfaction. Health care providers who administer vaccines covered by the national childhood vaccine injury act are required to ensure that.
I acknowledg e that a i understand the purposebenefits of my states immunization. Record the funding source of the vaccine given as either f federal, s state, or p private. Vaccine administration record for adults patient name. See page 1 to record tdaptd, hepatitis a, hepatitis b, hpv, mmr, varicella. I have been given a copy and have read or had explained to me the information contained in the appropriate cdc vaccine information materials vims about the vaccine s indicated below. Live vaccines flu nasal spray, zvl, chicken pox, mmr, oral typhoid answer questions 912 if you are receiving any immunizations listed. With the exception of hepatitis b vaccines, record the generic abbrevia tion e.
Vaccine administration centers for disease control and. I have read the vaccine information sheets vis for my vaccine and understand the benefits and risks of the vaccine and choose to assume that risk. When combination vaccines are given, enter the vaccine information in each separate vaccine row. Information collected on this form will be used to document authorization for receipt of vaccine s. Each vaccine has a recommended administration route and site, which are based on clinical trials, practical experience, and theoretical considerations. Source of vaccine federal, state, or private vaccine manufacturer and lot number.
Vaccine administration record for children and teens pdf icon external icon. Vaccine administration record var informed consent for vaccination 12fl0001 section a please print clearly. Vaers table of reportable events following vaccinationpdf icon external icon. Vaccine administration record var informed consent patient. A free vaccine administration elearn is available that offers continuing education for health care personnel, including cme, cne, ceu, cpe, cph, and ches. 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. Record the source of the vaccine given as either f federallysupported, s statesupported, or p supported by private insurance or other private funds. Vaccine administration record var informed consent for vaccination for all healthcare providers section a please print clearly. Record the generic abbreviation for the type of vaccine given e. Information may be shared through the north dakota immunization information system ndiis with other entities in accordance with north dakota century code 230105.
Datedate given dtap infanrix tripedia daptacel gsk sano. Vaccine s to be given route vis date1 manufacturer2 lot number sp3 admin. Vaccine administration record for children and teens patient name. Vaccine administration record varinformed consent for. Date on vis 2 date given 2 vaccine information statement signature initials of vaccinator 1. Vaccine administration record for adults state of michigan. Vaccine administration record var thrifty white pharmacy.
Record the publication date of each vis as well as the date the vis is. Vaccine administration record var informed consent for. Georgia vaccine administration record vaccine circle statements place v in box c if combination vaccine given e. Document the vaccinations health care providers are required by law to record certain information in a patients medical record. Date manufacturer dosage injection site vis date fluvirin iii 20162017 168723 04302017 seqirus 0. Viss, which explain the risks and benefits of vaccination, are available on. Faqs related to vaccine policy effective october 1, 2012. Signature and title of person administering vaccine. For vaccines that have a diluent or buffer, complete the following. Home phone date of birth age gender male female first name mi last name home address city state zip code email address medicare part b number if applicable. Vaccine administration record for children and teens pneumococcal e. Vaccine source code description of vaccine source code. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.
Designed for tracking pertinent vaccine administration data and also provides space for parent or legal guardian approvals. Update the patients record with any new allergy, health condition or primary care provider information. Vaers table of reportable events following vaccinationpdf iconexternal icon. By signing this form i acknowledge this recommendation. Vaccine administration record var informed consent for vaccination healthcare providers can be an immunizationcertified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physicians assistant. Marion county health department strongly recommends that all persons receiving vaccines wait 15 minutes for observation before leaving the clinic due to possible fainting, allergic reactions, and other potential injuries. Vaccine administration record for adults connecticare. Vaccine administration record var adult 19 years and older for the. Have you ever fainted or felt dizzy after receiving an immunization. Vaccine administration record var informed consent for vaccination. Update the patients personal record card or provide a new one whenever you administer the vaccine.
Section a please print clearly cell phone date of birth age gender male female first name mi last name home address city state zip code primary care physician name physician phone. Vaccine administration record for adults immunization action. Vaccine administration record var informed consent for vaccination for all health care providers patient. 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. Fill out, securely sign, print or email your vaccine administration record var for children and teens public health oregon instantly with signnow. Are you currently sick with a moderate to high fever, vomitingdiarrhea. Family planning var north dakota department of health. Vaccine administration record for adults pennsylvania. Record the publication date of each vis as well as the date it is given to the patient. Vaccine administration record for adults pdf icon external icon. Vaccine administration record varinformed consent for vaccination. Record the route by which the vaccine was given as either intramuscular.
Section a please print clearly cell phone date of birth age gender. Birthdate mmddyy 42 medical notes allergies, vaccine reactions, etc. Vaccine administration record for children and teens. Private p vaccine purchased using other than government funds i. Flu vaccine administration record i have read or have had explained to me the information in the vaccine information statement vis.
You must file a vaccine adverse event by calling 18777210366 or logging on to. Eligibility can be documented in paper form using the vaccine administration record pdf form or electronically in the providers electronic medical record. Reporting administered vaccines doses vfcenrolled providers are also required to report administered vaccine doses for all vfc eligible patients to the vfc program through the city. Vaccine administration record var informed consent for vaccination section a please print clearly. Last name first name mi division of public health h. Start a free trial now to save yourself time and money. As with all medical treatment, there is no guarantee that i will not experience an adverse side effect from the vaccine s. Date manufacturer dosage injection site vis date fluvirin 20152016 1514801 05302016 novartis 0. Providing a social security number will help make sure my immunization record is accurate and uptodate. Home phone date of birth age gender male female first name mi last name immunization location home address city state zip code email address medicare part b number if applicable.
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