This form was created by the Immunization Action Coalition www - odh ohio 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, birthdate, and chart number at the top of the form.
3. Fill in the clinic name and address where the vaccinations are administered.
4. For each vaccine administered, record the type of vaccine using either its generic abbreviation or trade name from the provided table.
5. Indicate the date given in the format (mo/day/yr) for each vaccine entry.
6. Specify the funding source as either F (federal), S (state), or P (private).
7. 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).
8. Record the lot number and manufacturer for each vaccine, ensuring accuracy for future reference.
9. Finally, sign off with your initials and title as a vaccinator to complete each entry.

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