Vaccine Administration Record

    PATIENT NAME:____________________________________________________________

   DATE OF BIRTH:____________________________________________________________

   PROVIDER NAME:____________________________________________________________

         ADDRESS:____________________________________________________________

 CITY, STATE ZIP:____________________________________________________________


*SITE ROUTE LEGEND 
    RA = Right Arm       PO = Oral 
    LA = Left Arm        IM = Intramuscular 
    RT = Right Thigh     SQ = Subcutaneous
    LT = Left Thigh 
 
 
CIRCLE VACCINE                 DATE   SITE/   VACCINE  VACCINE  VIS   MD/RN     PARENT/     VFC
                               GIVEN  ROUTE*  MANUF.   LOT #    DATE  INITIALS  GUARDIAN/   ELIGIBILITY
                               M/D/Y                                            SIGNATURE/  CHECK FOR YES
                                                                                DESIGNEE/ 

DTaP DTaP/Hib/IPV DT           _____  ______  _______  _______  ____  ________  __________  _____________

DTaP DTaP/Hib/IPV DT           _____  ______  _______  _______  ____  ________  __________  _____________

DTaP DTaP/Hib/IPV DT           _____  ______  _______  _______  ____  ________  __________  _____________

DTaP              DT           _____  ______  _______  _______  ____  ________  __________  _____________

DTaP DTaP/IPV     DT           _____  ______  _______  _______  ____  ________  __________  _____________

Hep A                          _____  ______  _______  _______  ____  ________  __________  _____________

Hep A                          _____  ______  _______  _______  ____  ________  __________  _____________

Hep B                          _____  ______  _______  _______  ____  ________  __________  _____________

Hep B                          _____  ______  _______  _______  ____  ________  __________  _____________

Hep B                          _____  ______  _______  _______  ____  ________  __________  _____________

Hib          DTaP/Hep B/IPV    _____  ______  _______  _______  ____  ________  __________  _____________

Hib HepB/Hib DTaP/Hep B/IPV    _____  ______  _______  _______  ____  ________  __________  _____________

Hib HepB/Hib DTaP/Hep B/IPV    _____  ______  _______  _______  ____  ________  __________  _____________

Hib HepB/Hib DTaP/Hep B/IPV    _____  ______  _______  _______  ____  ________  __________  _____________

HPV                            _____  ______  _______  _______  ____  ________  __________  _____________

HPV                            _____  ______  _______  _______  ____  ________  __________  _____________

HPV                            _____  ______  _______  _______  ____  ________  __________  _____________

Influenza                      _____  ______  _______  _______  ____  ________  __________  _____________

Influenza                      _____  ______  _______  _______  ____  ________  __________  _____________

IPV                            _____  ______  _______  _______  ____  ________  __________  _____________

IPV                            _____  ______  _______  _______  ____  ________  __________  _____________

IPV                            _____  ______  _______  _______  ____  ________  __________  _____________

IPV                            _____  ______  _______  _______  ____  ________  __________  _____________

Meningococcal Conjugate (MCV4) _____  ______  _______  _______  ____  ________  __________  _____________

MMR MMRV                       _____  ______  _______  _______  ____  ________  __________  _____________

MMR MMRV                       _____  ______  _______  _______  ____  ________  __________  _____________

PCV 7                          _____  ______  _______  _______  ____  ________  __________  _____________

PCV 7                          _____  ______  _______  _______  ____  ________  __________  _____________

PCV 7                          _____  ______  _______  _______  ____  ________  __________  _____________

PCV 7                          _____  ______  _______  _______  ____  ________  __________  _____________

Pneumococcal Polysaccharide    _____  ______  _______  _______  ____  ________  __________  _____________

Rotavirus                      _____  ______  _______  _______  ____  ________  __________  _____________
 
Rotavirus                      _____  ______  _______  _______  ____  ________  __________  _____________

Rotavirus                      _____  ______  _______  _______  ____  ________  __________  _____________

Td                             _____  ______  _______  _______  ____  ________  __________  _____________

Td Tdap                        _____  ______  _______  _______  ____  ________  __________  _____________

Varicella                      _____  ______  _______  _______  ____  ________  __________  _____________

Varicella                      _____  ______  _______  _______  ____  ________  __________  _____________

Other:_____________________    _____  ______  _______  _______  ____  ________  __________  _____________



DELAWARE HEALTH AND SOCIAL SERVICES . Division of Public Health . Immunization Program 1-800-282-8672