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.
- English (PDF: 69KB/1 page) updated 11/13
- Somali (PDF: 71KB/1 page) updated 11/13
- Spanish (PDF: 71KB/1 page) updated 11/13
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.
- English (PDF: 70KB/1 page) updated 11/13
- Somali (PDF: 70KB/1 page) updated 11/13
- Spanish (PDF: 70KB/1 page) updated 11/13