Dhec form 1103v 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and ID number at the top of the form. This information is crucial for accurate record-keeping.
3. For each vaccine administered, fill in the date given, injection site, manufacturer, lot number, and VIS date. Use our platform's text fields to ensure clarity.
4. Circle the appropriate administration route (IM, SC, PO) for each vaccine using the editing tools available in our editor.
5. In the Provider ID section, have the administering provider sign their name and add initials for future visits. This can be done electronically on our platform.
6. Select the eligibility status from the provided table and enter the corresponding number for each vaccine administered.
7. If applicable, check the box indicating a reliable history of Chickenpox and note the date checked.
8. Document any allergies or comments in the designated section to provide comprehensive patient information.
9. Finally, retain this completed form in the patient's medical record for future reference.

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