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The form captures patient identifiers, vaccine type and dates, funding source, route and injection site, vaccine lot and manufacturer details, VIS publication and administration dates, and vaccinator signatures or initials. 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any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure they understand the risks and benefits of the vaccine(s). Always provide or update the patient’s personal record card.  \nPAGE 1 0F 2  \nPatient name   Birthdate   Chart number    \npractice name and address  \n\n| Vaccine | Type of\u003Cbr>Vaccine1 | Date Vaccine\u003Cbr>Given\u003Cbr>(mo/day/yr) | Funding\u003Cbr>Source\u003Cbr>(F,S,P)2 | Route\u003Cbr>& Site3 | Vaccine |  | Vaccine Information Statement (VIS) |  | Vaccinator5\u003Cbr>(signature or\u003Cbr>initials and title) |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  | Lot \\# | Mfr. | Date on VIS4 | Date given4 |  |\n| Tetanus, Diphtheria, Pertussis\u003Cbr>(e.g., Tdap, Td)\u003Cbr>Give IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| Hepatitis A6\u003Cbr>(e.g., HepA, HepA-HepB) Give IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| Hepatitis B6\u003Cbr>(e.g., HepB, HepA-HepB) Give IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| Human papillomavirus\u003Cbr>(HPV) Give IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| Measles, Mumps, Rubella\u003Cbr>(MMR)\u003Cbr>Give MMRII Subcut or IM; give Priorix Subcut.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| Varicella (VAR)\u003Cbr>Give Subcut or IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| MeningococcalACWY6\u003Cbr>(e.g., MenACWY, MenABCWY)\u003Cbr>Give IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| Meningococcal B6\u003Cbr>(e.g., MenB-4C, MenBFHbp, MenABCWY)\u003Cbr>Give IM.3 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n\n\n| Abbreviation | Trade Name and Manufacturer |\n| --- | --- |\n| Tdap | Adacel (Sanofi); Boostrix (GSK) |\n| Td | Tenivac (Sanofi); Tdvax (MA Biological Labs) |\n| HepA | Havrix (GSK); Vaqta (Merck) |\n| HepB (see note \\#1) | Engerix-B (GSK); Recombivax HB (Merck); Heplisav-B (Dynavax) |\n| HepA-HepB | Twinrix (GSK) |\n| HPV | Gardasil 9 (Merck) |\n| MMR | MMR II (Merck); Priorix (GSK) |\n| VAR | Varivax (Merck) |\n| MenACWY | MenQuadfi (Sanofi); Menveo (GSK) |\n| MenB-4C\u003Cbr>(see note \\#1) | Bexsero (GSK) |\n| MenB-FHbp\u003Cbr>(see note \\#1) | Trumenba (Pfizer) |\n| MenABCWY\u003Cbr>(see note \\#1) | Penbraya (Pfizer); Penmenvy (GSK) |\n\ncontinued on the back   \nHow to Complete this Record  \n1. For hepatitis B and meningococcal B vaccines (MenB or MenABCWY), record the trade name (see table at left); for all other vaccines, record the standard abbreviation (e.g., Tdap) .  \n2. Record the funding source of the vaccine given as either F (federal), S (state), or P (private) .  \n3. Record the route by which the vaccine was given as either intramuscular (IM), subcutaneous (Subcut), or intranasal (NAS), and also the site where it was administered as either RA (right arm), LA (left arm), RT (right thigh), or LT (left thigh).  \n4. Record the publication date of each VIS as well as the date the VIS is given to the patient.  \n5. To meet the space constraints of this form and federal requirements for documentation, a healthcare setting should keep a reference list of vaccinators that includes their initials and titles.  \n6. For combination vaccines, fill in a row for each antigen in the combination.  \nFOR PROFESSIONALS [www.immunize.org /](www.immunize.org / FOR THE PUBLIC)[ FOR THE PUBLIC](www.immunize.org / FOR THE PUBLIC) [www.vaccineinformation.org](www.vaccineinformation.org)  \n[www.immunize.org/catg.d/p2023.pdf](www.immunize.org/catg.d/p2023.pdf)  \nItem \\#P2023 (5/31/2025)   \nScan for PDF  \nPAGE 2 0F 2  \nVaccine Administration Record for Adults (continued)  \nBefore administering any vaccines, give the patient copies of all pertinent Vacci","cbCaimpN3jAprfwG","https://ap.wps.com/l/cbCaimpN3jAprfwG","pdf",292760,"English","# How to Complete this Record\n## Record requirements\n## Combination vaccine entries\n## Trade name and reference list","[{\"question\":\"What must be provided to the patient before administering vaccines?\",\"answer\":\"Provide the patient copies of all pertinent Vaccine Information Statements (VISs) and ensure the patient understands the risks and benefits of the vaccine(s).\"},{\"question\":\"What information does the record capture for each vaccine?\",\"answer\":\"For each administered vaccine, the record captures date given, funding source, route and site, lot number, manufacturer, VIS publication date, VIS date given to the patient, and vaccinator signature or initials and title.\"},{\"question\":\"How should hepatitis B and meningococcal B vaccines be documented regarding trade names?\",\"answer\":\"For hepatitis B and meningococcal B vaccines (MenB or MenABCWY), record the trade name using the table at left rather than the standard abbreviation.\"}]","Vaccine Administration Record for Adults - Adult Vaccination Documentation Form | PDF",1789974028]