Vaccine Administration Records

Forms to use for vaccination clinics. Collect the signature of your patients when administering vaccine on these handy forms.

Note: Federal and Minnesota state law do not require signatures acknowledging receipt of VISs.

On this page:
Adult
Pediatric

Adult Vaccine Administration Records

Form used to record patient signatures during vaccination clinics. Record the immunization given to your adult patients including the dose, lot number, manufacturer, VIS given, site given, and signature of vaccinee or authorized representative.

Pediatric Vaccine Administration Records

Form used to record patient signatures during vaccination clinics. Record the immunization given to your pediatric patients including the dose, lot number, manufacturer, VIS given, site given, and signature of vaccinee, parent, or authorized representative.

 

Updated Friday, 27-Dec-2013 09:39:35 CST