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This form was created by the Immunization Action Coalition www - odh ohio

This form was created by the Immunization Action Coalition www - odh ohio 2025

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The document is a Vaccine Administration Record for children and teens, detailing the process for administering vaccines, including the requirement to provide Vaccine Information Statements (VISs) to parents or guardians. It includes sections for recording patient information, vaccine types, dates given, funding sources, administration routes and sites, and details about each vaccine's manufacturer and lot number. The document emphasizes the importance of understanding the risks and benefits of vaccines before administration.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, birthdate, and chart number at the top of the form.
Fill in the clinic name and address where the vaccinations are administered.
For each vaccine administered, record the type of vaccine using either its generic abbreviation or trade name from the provided table.
Indicate the date given in the format (mo/day/yr) for each vaccine entry.
Specify the funding source as either F (federal), S (state), or P (private).
Document the route and site of administration, such as IM for intramuscular or SC for subcutaneous, along with specific locations like RA (right arm) or LA (left arm).
Record the lot number and manufacturer for each vaccine, ensuring accuracy for future reference.
Finally, sign off with your initials and title as a vaccinator to complete each entry.

Start filling out your Vaccine Administration Record today using our platform for free!

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2023	4.3 Satisfied (25 Votes)
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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I get my immunization records from Ohio?

Should students or student health offices complete the form? Students should complete the AAMC Standardized Immunization Form in conjunction with either the student health office at their medical school or with their primary care provider.

Who can fill out my immunization form?

Go to My Record Health Summary and select the Immunizations tab. You can see the immunizations youve received and the dates on which you received them. Click the immunization name to learn more. If your immunizations are not up to date, please docHub out to your clinic directly to have your information updated.

How can I access my immunization records on mychart?

Reason of conscience or religious exemption: A student who presents a written statement of the pupils parent or guardian in which the parent or guardian declines to have the pupil immunized for reasons of conscience, including religious convictions (Ohio Revised Code 3313.671).

How do I get a copy of my immunization records in Ohio?

If you need vaccination records, you can: Ask your healthcare provider, who will have a copy of your medical records and may be able to access the state system. Contact your local health department, which may be able to access the state system. To find your health department, go to odh.ohio.gov/local.