January 2010




Vaccine Administration Record for Children and Teens

1. Record the generic abbreviation for the type of vaccine given (e.g., DTaP-Hib, PCV), not the trade name. 2. Record the source of the vaccine given as either F (Federally-supported), S (State- supported), or P (supported by Private insurance or other Private funds). 3. Record the site where vaccine was administered as either RA (Right Arm), LA (Left Arm), RT (Right Thigh), LT (Left Thigh), IN (Intranasal), or po (by mouth). 4. Record the publication date of each VIS as well as the date it is given to the patient. 5. For combination vaccines, fill in a row for each separate antigen in the combination.