Immunization Information Form (DHEC 1103V) (pdf) - Department of ... - scdhec 2026

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Click ‘Get Form’ to open the Immunization Information Form (DHEC 1103V) in the editor.
Begin by entering the patient's name, date of birth, and ID number at the top of the form.
For each vaccine administered, record the date given, injection site, manufacturer, lot number, and VIS date in the corresponding fields.
Circle the appropriate administration route for each vaccine: IM for Intramuscular, SC for Subcutaneous, PO for Oral.
Select the eligibility status from the provided table and enter it in the Eligibility Status column for each vaccine.
If applicable, check 'yes' for a reliable history of Chickenpox and note the date checked.
Document any allergies or comments in the designated section.
Finally, ensure that all information is accurate before saving your completed form.

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