C.M.R. 10, 144, ch. 208, app 144-208-D
Current through 2024-51, December 18, 2024
Name: _____________________ Birthdate: _____________________________
Before administering any vaccines, give the parent/legal representative all appropriate copies of Vaccine Information Statements (VIS's) and make sure they understand the risks and benefits of the vaccine(s). Update the patient's personal record card or provide a new one whenever you administer vaccine.
PLEASE INDICATE ALL KNOWN DATES OF IMMUNIZATION OR ILLNESS
| Vaccine | Type of Vaccine 1 | Date given (mo/day/yr) | Source (S or P) 2 | Site 3 | Route (IM, SC, IN or Oral) | Vaccine | Vaccine Information | Results:Positive/Negative. | ||
| Lot # | Mfr. | Date on VIS 4 | Date given/ Initials | |||||||
| Diphtheria, Tetanus, Pertussis (e.g.DTaP, DTaP-Hib, DTaP-HebB-IPV, DT, Tdap, Td) Route IM. | ||||||||||
| Polio (e.g., IPV, Dtap-HebB-IPV) IPV Route SC or IM DtaP-HepB-IPV Route IM. | ||||||||||
| Measles, Mumps, Rubella (e.g., MMR, MMRV) Route SC. | ||||||||||
| Haemophilus influenzae type b (e.g., Hib, Hib-HepB, DTaP-Hib) Route IM. | ||||||||||
| Hepatitis B (e.g., HepB, Hib-HepB, DTaP-Hib) Route IM. | ||||||||||
| Varicella (e.g., Var, MMRV) Route SC. | ||||||||||
| Pneumococcal (e.g., PCV, conjugate; PPV, polysaccharide) PCV Route IM. PPV Route SC or IM. | ||||||||||
| Rotavirus (Rv) Route Oral Never given after 32 weeks of age | ||||||||||
| Hepatitis A or C (HepA, HepC) Route IM. | ||||||||||
| Human Papillomavirus (HPV) Route IM. | ||||||||||
| Meningococcal (e.g., MCV4, conjugate; MPSV4, polysaccharide MCV4 Route IM. MPSV4 Route SC. | ||||||||||
| Influenza (e.g., TIV, inactivated; LAV, live attenuated) RouteTIV IM. Route LAIV IN. | ||||||||||
| TB Mantoux Test | ||||||||||
| Other | ||||||||||
C.M.R. 10, 144, ch. 208, app 144-208-D