Forms for Tracking Patient Immunizations
Keep track of your patients’ immunization information on these handy forms.
On this page:
Paper forms for health professionals
Online electronic reporting
Forms for patient use
Paper forms for health care providers
Forms for use in patients' medical chart:
Tip: Keep the immunization record forms in the front of medical charts so you remember to check immunizations at every visit.
- Pediatric Immunization
Record (PDF: 194KB/2 pages)
Record the immunization given to your pediatric patients, including dose, lot number, manufacturer, VIS given, and site given. Also available as a sticker for the inside cover of the medical chart. To order stickers, call 800-657-3970 or 651-201-5503. Updated 9/11
- Adult Immunization
Record (PDF: 151KB/2 pages)
Record the immunization given to your adult patients, including dose, lot number, manufacturer, VIS given, and site given. Also available as a sticker for the inside cover of the medical chart. To order stickers, call 800-657-3970 or 651-201-5503. Updated 11/11
- Patient
Immunization Record (PDF: 35KB/2 pages)
Record the immunization given to your patients, including dose, lot number, manufacturer, VIS given, and site given. Use this one-size-fits-all form to record immunizations for infants, children, teens, and adults. Updated 3/11
Forms for use during vaccination clinics:
Note: Federal and Minnesota state law do not require signatures acknowledging receipt of VISs.
- Adult Vaccine Administration
Record
Form used to record patient signatures during vaccination clinics. The form records the immunization given to adult patients including the dose, lot number, manufacturer, site given, VIS given, and signature of vaccinee or authorized representative. Also available in other languages. Updated 12/06
- Pediatric Vaccine
Administration Record
Form used to record patient signatures during vaccination clinics. The form records the immunization given to pediatric patients including the dose, lot number, manufacturer, site given, VIS given, and signature of vaccinee or authorized representative. Also available in other languages. Updated 12/06
Online electronic reporting
- Minnesota Immunization
Information Connection (MIIC)
The confidential, computerized information system which contains a complete and accurate record of a person's immunizations, no matter where they got those shots.
Forms for patient use
- Keeping Track
of Immunizations
Give your patients these resources to track immunizations for children.
Frequently Requested
VISs
CDC fact sheets on vaccines.
Attention: Non-MDH link
CDC Immunization Home
Attention: Non-MDH link
If you have questions or comments about this page, use our IDEPC Comment Form or call 651-201-5414 (TTY: 651-201-5797) for the MDH Infectious Disease Epidemiology, Prevention and Control Division.
