Documenting Shots - health.state.mn.us€¦ · This section is filled with tips and tools to make documenting shots a more accurate, less complicated task. Overview of this section:

This section is filled with tips and tools to make documenting shots a more accurate, less complicated task.

Overview of this section:

Best Practices Checklist: Documenting Shots

Why Document Shots

How to Document Shots

Where to Document Shots

Documenting for Child Care and School

Key Resources for Documenting Shots

Remember:"If it isn't

documented, it isn't done!"

Who to CallMIIC Help Desk

651-201-5503 800-657-3970

Minnesota Immunization Program For Minnesota specific issues (e.g. Minnesota school law)

800-657-3970651-201-5503

181July 2011, Minnesota Department of Health Got Your Shots? Providers Guide - DOCUMENTING SHOTS www.health.state.mn.us/immunize

Documenting ShotsIt would be much easier if we all did it the same way!

How to document shots � We train our staff on what immunization

documentation is essential and required by law.

� We keep accurate, readable, up-to-date immunization records.

� We participate in the Minnesota Immunization Information Connection (MIIC) to ensure vaccination records are available.

Where to document shots � We always update the patient’s personal

immunization record with information on the vaccines we administer.

� We update the patient immunization record with vaccines received at other clinics, when we have appropriate documentation.

� We make sure patients don't leave without a personal immunization record that contains their immunization history.

� If we don't give a vaccine when it's due, we document the reason why in the patient’s chart.

Documenting for child dare and school � We train staff on documentation required

for child care and school under Minnesota's immunization law.

Best Practices Checklist: Documenting ShotsThe information in this checklist will be covered in more detail throughout this section.

182 www.health.state.mn.us/immunize Got Your Shots? Providers Guide - DOCUMENTING SHOTS Minnesota Department of Health, July 2011

Why records are importantWritten or electronic documentation is the only way to make sure your patient:

y Receives the shots he or she needs at the recommended age and intervals. y Isn't over-vaccinated – which is not only costly but painful. y Has the shots needed for child care and school, or for a job or international

travel.

What immunization information is needed or required?Every time you give an immunization, certain information must be documented in the patient's immunization record – either because it is required by federal law or it is necessary to document administration of a prescribed drug (e.g., vaccines). See the table Documenting Vaccine Information on pages 184-185. Additional documentation may be required by state regulation or your facility. Be sure your facility has a written policy that describes what documentation is necessary and where it should be documented.

Required by federal lawFederal law requires you to document the following information as part of the National Childhood Vaccine Injury Act when you administer recommended vaccines to children as well as adults; see Immunization Laws on page 203

y Date vaccine given y Date of publication of the Vaccine Information Statement (VIS) (see

Instructions for the Use of Vaccine Information Statements on page 143.) y Date the VIS was given to the patient (or parent/legal guardian) y Manufacturer and lot number of vaccine y Name, title, and clinic address (location where immunization information will

be stored) of the individual who administered the vaccine

Essential to documentAs a best practice for documenting immunizations, the following additional information is essential to document:

y Vaccine type y Route and site of administration y Dosage y History of a vaccine reaction y Contraindications y Patient's date of birth

Why Document

Shots

How to Document

Shots




Documenting Vaccine InformationHow to record ... Guideline Example(s)

Required by federal law

Date vaccine given Use MM/DD/YYYY. 06/24/2010

Date on VIS Document the month, day, and year found on the VIS itself; use MM/DD/YYYY. 08/10/2010

Date VIS given to patient

Document the month, day, and year the VIS was given to the parent (or vaccinee); use MM/DD/YYYY.

10/10/2010

Vaccine manufacturer

Use 3-character abbreviation; these codes are universal and the same codes used by MIIC.

MSD for Merck & Co, Inc. See Vaccine Manufacturers for Selected Childhood and Adult Vaccines on page 201.

Vaccine lot number

Indicate the lot number as printed on the vial, syringe, or box. For combination vaccines use the lot number on the box; it is linked to the vaccine diluent and powder.

470-5275160C9

Person administering vaccine

Document name and title of person administering vaccine. Mary Jones, RN

Document the address of the clinic where the vaccine was administered.

Main St. Clinic, 1111 Main St., City, MN 55555

Essential to record

Vaccine type

Use standardized vaccine abbreviations. Hib, HepB, DTaP (See table on page 199.)

Use numbers or additional letters, if necessary, to distinguish different vaccines for the same disease.

Hib(PRP-T), Hib(PRP-OMP), HPV2, HPV4

Note: Indicating the type of vaccine is important when you give DT-pediatric rather than DTaP since children who receive DT-pediatric will be at higher risk of pertussis disease if there is a pertussis outbreak in the community.

Continued



Essential to record, continued

Combination vaccines

Document a combination vaccine under each specific antigen the vaccine contains; use a hyphen between each antigen.

y Pentacel is DTaP-IPV-Hib. Record it under DTaP, IPV, and Hib.

y Twinrix is hepA-hepB. Record it under both hepatitis A and hepatitis B.

y Pediarix is DTaP-IPV-hep B. Record it under DTaP, IPV, and hepatitis B

Route of administering vaccine

Document method of administration.Intramuscular (IM), subcutaneous (SQ or SC), oral (PO), intranasal (ITN)

Site of administering vaccine

Document location of administration. Right thigh (RT), left thigh (LT), right arm (RA), left arm (LA)

Dosage Document the vaccine dosage. 0.5 mL, 1.0mL

History of vaccine reaction

If a patient experiences a clinically significant or unexpected event after an immunization (even if you are uncertain the vaccine caused it), provide specifics about the event in the patient's chart. See Report adverse reactions to vaccines on page 160.

ContraindicationsIndicate any vaccine contraindications the patient has; provide specifics in the patient's chart. See Contraindications and Precautions to Commonly Used Vaccines on page 135-138.

Patient's date of birth Use MM/DD/YYYY. 04/24/2010


Documenting immunizations in the patient's medical recordWhether you document immunizations on paper or electronically, make sure to include all of the required and essential information. See What immunization information is needed or required? on page 183.

► Paper medical recordsDocument all vaccinations received on the immunization and/or medical record. Consider using the Patient Immunization Record form on pages 193-194. It not only makes it easy to collect all the information you need, but also:

y Accommodates all the legally required immunization data as well as other information you need

y Can be used for both pediatric and adult patients y Has easy-to-follow directions on the back of the form y Has the space to document all immunizations on one page y Has space to document immunizations given elsewhere y Allows notation of any reactions to vaccines y Can be copied and transferred to a patient’s new clinic y Helps Minnesota clinics and others gear up for electronic documentation

► Minnesota Immunization Information Connection (MIIC)Document all immunizations given at your clinic into MIIC, the statewide immunization registry. Make sure you enter all the information required by MIIC and follow up on any alerts you encounter in the process.

Note: In some clinics, you don't need to enter immunization data into MIIC because it is updated via the electronic transfer of the EHR or by the clinics billing department.

► Electronic health records (EHR)Document all immunizations received in the patient’s EHR. Make sure you are familiar with the information required by your EHR system and follow up on any alerts you encounter in the process.

Are you moving toward an electronic health record system but not quite there yet? Consider using the Patient Immunization Record form on pages 193-194 as a template, because it includes all the legally required elements. Don't get stuck having to make changes later to comply with federal law, which can be costly.

Use the tools in your EHR or MIIC or to create lists of patients whose immunizations are overdue and generate recall notices or labels for reminder cards.

If patients have received vaccine elsewhereInclude information regarding vaccines that patients received at other clinics to their medical record. If you don’t have complete information, document at least the date (mm/dd/yyyy) and type of vaccine. The responsibility for maintaining the federally required information is with the clinic that administered the vaccine; see the table What immunization information is needed or required? on page 183.



MIIC can help MIIC (Minnesota Immunization Information Connection), the statewide immunization registry, is a program used by health care providers, public health agencies, health plans, and schools to record, monitor, and view immunization information. MIIC uses a confidential, computerized information system to consolidate immunization information.

The benefits of MIIC include:

y Consolidating immunizations a person has received into a single record, no matter where in Minnesota they received the shots.

y Providing an accurate, official copy of a persons immunization history for child care, school, camp enrollment, medical records, or for personal records.

y Ensuring a person's immunizations are up to date by assessing the immunization status and identifying immunizations due or overdue.

y Offering access to a reminder system. y Providing recalls when an immunization has been missed. y Ensuring timely immunization for children whose families move or change

health care providers. y Preventing unnecessary (duplicative) immunization. y Providing easy 24/7 retrieval of immunization information during an

outbreak.

Give the patient a record to take homeYour patients need personal immunization records. Always update the patient’s personal immunization record with information on the vaccines that you administered. Here are some options:

► Paper medical recordsConsider using the Gold Card for personal immunization records. It is beneficial because it: y Can be used for both pediatric and adult patients. y Permits recording of all immunizations throughout a lifetime. y Allows recording of date for the next dose in a series. y Has space to record all information for children enrolling in child care,

school, or college. y Fits in a wallet and is durable (i.e., it’s rip-proof and smear-proof). y Compliments the MIIC record, particularly for providers who don't

participate in MIIC.

► Minnesota Immunization Information Connection (MIIC)Give the patient a printout of their personal immunization record from MIIC.

► Electronic health records (EHR)Give the patient a printout of their personal immunization record from your EHR system.

MIIC is located at https://miic.health.state.mn.us.

If you're not yet

participating, call 1-800-657-3970, or visit

www.health.state.mn.us/divs/idepc/immunize/

registry/index.html to find out how to enroll.

Gold cards are free! Order them by calling

800-657-3970, or 651-201- 5503, or by filling out

the order form at www.health.state.mn.us/

divs/idepc/immunize/ordermat.html


Use MIIC and simplify the

work of schools in enforcing the School Immunization Law.

Documenting for Child Care and School

Minnesota's child care / school immunization law and documentationAccurate documentation of immunization(s) helps patients meet Minnesota's child care and school immunization requirements. By law, providers must document either that: y Recommended immunizations have been completed, or y Recommended immunizations have been initiated but are still in process, or y The child has a legal medical exemption to one or more recommended

vaccines. y Note: The patient/parent may also submit documentation of a conscientious

exemption to one or more immunizations.

Troubleshooting documentation for child care and schoolSpecifics of the immunization law and documentation can be complex. Use the table, Getting Your Patient “Immunization Ready” for School on page 189 to guide you.

► Paper medical recordsChild Care and Pupil Immunization Record formThe Child Care Immunization Record form and the Pupil Immunization Record form, see pages 195-198, contain all the essential pieces of documentation needed to satisfy the law, including:

y Spaces to document all vaccines given that are required by law. y A place to document that a required vaccine series has been initiated but

not yet completed. y A place for the provider to indicate a legal medical exemption (e.g.,

contraindication to a vaccine, history of disease). y A place for parents to indicate conscientious objection and have their

signature notarized.

► Minnesota Immunization Information Connection (MIIC)You can use the printed record from MIIC as an official copy of a child's immunization history for child care, school, or camp. Additionally, school nurses can use MIIC to look up students' immunizations and monitor completion of required vaccinations.

► Electronic health records (EHR)You can use the printed record from your EHR as an official copy of a child's immunization history for child care, school, or camp.

More on Minnesota's School Immunization LawFor more information on Minnesota's School Immunization Law (Minnesota Statutes, section 121A.15), see Provider's Quick Reference on Minnesota's Immunization Laws on pages 133-134. Also visit the MDH web site at www.health.state.mn.us/divs/idepc/immunize/laws/index.html.


Reminder: Children whose

parents are opposed to immunization can legally

enroll in child care or school. Parents can use the Child Care or Pupil Immunization Record

form to file a legal exemption.

Getting Your Patient “Immunization Ready” for SchoolImmunization status Provider responsibilities

Children who have completed all their recommended immunizations

y Complete, sign (if necessary), and give the parent the Child Care or Pupil Immunization Record form; see pages 195-198, or

y Provide a MIIC printout, or y Complete, sign, and give the parent a

record that includes the dates (mm/dd/yyyy) of vaccines given.

Children who have not completed recommended immunizations

y Complete the Child Care or Pupil Immunization Record form to document vaccines given to date and sign the record indicating when additional dose(s) are due.

Children with a medical contraindication to a vaccine or vaccines

y Complete and sign the portion of the Child Care or Pupil Immunization Record form that verifies a medical exemption.

Children with laboratory evidence of immunity to a disease covered by the law

y Complete and sign the portion of the Child Care or Pupil Immunization Record form that verifies a medical exemption due to history of disease (provide date of diagnosis) or lab evidence of immunity (provide date of testing).

y Note: There is a specific place to document a child’s history of varicella disease.

Children whose parent(s)are conscientiously opposed to immunizations

y Discuss consequences to the child’s health if not immunized: risk of disease to the child, risk of spreading disease to other children, and the possibility of the child being asked to stay home during a disease outbreak.

y If parent/guardian refuses vaccination for a child, it is their responsibility to give the child care or school a signed and notarized statement that specifies which vaccine(s) they oppose. They can use the Child Care or Pupil Immunization Record for this purpose.



y Patient Immunization Record (MDH) A one-size-fits-all form to document immunizations for infants, children, teens, and adults. www.health.state.mn.us/divs/idepc/immunize/hcp/ptimzrec.pdf

y Child Care Immunization Record (MDH) Form designed to provide child care facilities with immunization information required by Minnesota law.

www.health.state.mn.us/divs/idepc/immunize/laws/childcareimzrec.pdf

y Pupil Immunization Record (MDH) Form designed to provide schools with immunization information required by Minnesota law. www.health.state.mn.us/divs/idepc/immunize/pupilimzrec.pdf

y Data Elements Used in Recording Selected Childhood and Adult Vaccines Table listing vaccine names, trade names, manufacturers, CPT and CVX codes. www.health.state.mn.us/divs/idepc/immunize/registry/hp/vaxcodes.html

y Vaccine Manufacturers for Selected Childhood and Adult Vaccines Table listing vaccine manufacturers and the abbreviations used for electronic data exchange. www.health.state.mn.us/divs/idepc/immunize/registry/hp/vaxcodes.html

Key Resources for Documenting Shots



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nter

or s

ubm

it da

ta o

n ne

w s

hots

for t

his

patie

nt s

o it

is

avai

labl

e to

oth

ers

who

may

be

givi

ng s

ubse

quen

t dos

es. M

IIC is

loca

ted

at

http

s://m

iic.h

ealth

.sta

te.m

n.us

. If y

ou a

re n

ot y

et p

artic

ipat

ing,

cal

l 80

0-65

7-39

70, o

r vis

it w

ww.

heal

th.s

tate

.mn.

us/im

mun

ize

(clic

k on

“MIIC

R

egis

try”)

to fi

nd o

ut h

ow to

enr

oll.

Man

ufac

ture

rs’ c

odes

Use

the

code

s lis

ted

in th

e ch

art b

elow

to in

dica

te th

e m

anuf

actu

rer o

f the

va

ccin

e. T

hese

are

the

sam

e co

des

used

uni

vers

ally

and

by

the

Min

neso

ta

Imm

uniz

atio

n In

form

atio

n C

onne

ctio

n (M

IIC).

Vacc

ine

Man

ufac

ture

rC

ode

CS

L B

ioth

erap

ies

CS

LG

laxo

Sm

ithK

line

SK

BM

assa

chus

etts

Bio

logi

c La

bsM

BL

Med

Imm

une,

Inc.

M

ED

Mer

ck &

Co.

, Inc

. M

SD

Nov

artis

NO

Vsa

nofi

past

eur I

nc.

PM

CW

yeth

Vac

cine

sW

AL

Your

pat

ient

s ne

ed p

erso

nal i

mm

uniz

atio

n re

cord

car

dsAl

way

s up

date

the

patie

nt’s

per

sona

l im

mun

izat

ion

reco

rd w

ith in

form

atio

n on

th

e va

ccin

es th

at y

ou a

dmin

iste

red.

If y

our c

linic

nee

ds p

erso

nal i

mm

uniz

atio

n re

cord

car

ds, o

rder

the

MD

H G

old

Car

d by

cal

ling

800-

657-

3970

, or 6

51-2

01-

5503

, or b

y fi l

ling

out t

he o

rder

form

at w

ww.

heal

th.s

tate

.mn.

us/im

mun

ize.

How

to u

se M

DH

’s P

atie

nt Im

mun

izat

ion

Rec

ord

form

Imm

uniz

atio

n P

rogr

amP.

O. B

ox 6

4975

St.

Pau

l, M

N 5

5164

-097

565

1-20

1-55

03 o

r 1-8

00-6

57-3

970

ww

w.h

ealth

.sta

te.m

n.us

/imm

uniz

e

Available on the web at: www.health.state.mn.us/divs/idepc/immunize/hcp/ptimzrec.pdf


D.If

the

pare

nt/g

uard

ian

cons

cien

tious

ly o

ppos

es im

mun

izat

ions

:

I und

erst

and

that

not

follo

win

g va

ccin

atio

n re

com

men

datio

ns m

ay e

ndan

ger t

he h

ealth

or l

ife o

f my

child

and

oth

ers

that

my

child

mig

ht c

ome

in c

onta

ct w

ith. I

her

eby

certi

fy b

y no

tariz

atio

n th

at:

I am

opp

osed

to a

ll im

mun

izat

ions

.I a

m o

ppos

ed to

onl

y th

e va

ccin

es in

dica

ted.

Vac

cine

(s) I

opp

ose:

Sig

natu

re o

f Par

ent/G

uard

ian

Dat

e

Chi

ld C

are

Imm

uniz

atio

n R

ecor

dbe

fore

IMM

UN

IZAT

ION

HIS

TORY

: Fill

in th

e M

O/D

AY/Y

R in

form

atio

n fo

r chi

ldre

n 2

mon

ths

of a

ge

and

olde

r. If

child

rece

ived

a c

ombi

ned

shot

(lik

e H

ib-h

ep B

), w

rite

the

date

in a

ll th

e bo

xes

that

ap

ply.

Vac

cine

dos

es th

at a

re c

ircle

d

ar

e no

t req

uire

d by

law

.

Dip

hthe

ria, T

etan

us, P

ertu

ssis

(DTa

P)Va

ccin

eD

ose

MO

DAY

YR3

dose

s du

ring

1st y

ear

4th d

ose

at 1

2-18

mon

ths

5th d

ose

at 4

-6 y

ears

or a

t sch

ool e

ntra

nce

1 2 3 4 5Po

lio (I

PV a

nd/o

r OPV

)Va

ccin

eD

ose

MO

DAY

YR3

dose

s at

2-1

8 m

onth

s4th

dos

e at

4-6

yea

rs o

r at s

choo

l ent

ranc

e1 2 3 4

Mea

sles

, Mum

ps, R

ubel

la (M

MR

)Va

ccin

eD

ose

MO

DAY

YRR

equi

red

for c

hild

ren

15 m

onth

s an

d ol

der

Mus

t be

give

n on

or a

fter 1

st b

irthd

ay2nd

dos

e at

4-6

yea

rs

1 2

type

b (H

ib)

Vacc

ine

Dos

eM

OD

AYYR

3-4

dose

s fo

r chi

ldre

n at

2-1

5 m

onth

s1

dose

giv

en a

fter 1

2 m

onth

s or

old

er re

quire

d1

dose

for p

revi

ousl

y un

vacc

inat

ed c

hild

ren

15

-59

mon

ths

Not

indi

cate

d fo

r chi

ldre

n 5

year

s or

old

er

1 2 3 4Va

ricel

la (C

hick

enpo

x)Va

ccin

eD

ose

MO

DAY

YR1st

dos

e be

twee

n 12

-18

mon

ths

2nd d

ose

at 4

-6 y

ears

or a

t sch

ool e

ntra

nce

(req

uire

d fo

r kin

derg

arte

n)

1 2D

isea

se D

ate:

Pneu

moc

occa

l Con

juga

te V

acci

ne (P

CV)

Vacc

ine

Dos

eM

OD

AYYR

2-4

dose

s fo

r chi

ldre

n 2-

24 m

onth

sC

onsi

der f

or u

nvac

cina

ted

child

ren

at 2

4-59

m

onth

s in

chi

ld c

are

Not

indi

cate

d fo

r chi

ldre

n 5

year

s or

old

er

1 2 3 4H

epat

itis

B (H

ep B

)–re

quire

d fo

r kin

derg

arte

nVa

ccin

eD

ose

MO

DAY

YR3

dose

s be

twee

n bi

rth a

nd 1

8 m

onth

s1 2 3

Rot

aviru

sVa

ccin

eD

ose

MO

DAY

YR2-

3 do

ses

betw

een

2 an

d 6

mon

ths

1 2 3Va

ccin

eD

ose

MO

DAY

YR1

dose

ann

ually

for c

hild

ren

6 m

onth

s or

old

er(1

st

1 2H

epat

itis

A (H

ep A

)Va

ccin

eD

ose

MO

DAY

YR2

dose

s se

para

ted

by 6

mon

ths

for c

hild

ren

12

-24

mon

ths

1 2

A. Fo

r chi

ldre

n w

ho a

re 1

5 m

onth

s or

old

er a

nd w

ho h

ave

rece

ived

all

the

imm

uniz

atio

ns

requ

ired

by la

w fo

r chi

ld c

are:

I cer

tify

that

the

abov

e-na

med

chi

ld is

at l

east

15

mon

ths

of a

ge a

nd h

as c

ompl

eted

the

imm

uniz

atio

ns

whi

ch a

re re

quire

d by

law

for c

hild

car

e.

Sign

atur

e of

Par

ent/G

uard

ian

or P

hysi

cian

/Nur

se P

ract

itione

r/Phy

sici

an A

ssis

tant

/Pub

lic C

linic

D

ate

Nam

e:

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

__

Birt

hdat

e: _

____

____

____

____

____

____

_D

ate

of E

nrol

lmen

t: __

____

____

____

____

___

B.Fo

r chi

ldre

n w

ho a

re y

oung

er th

an 1

5 m

onth

s O

R h

ave

not r

ecei

ved

all r

equi

red

imm

uniz

atio

ns:

I cer

tify

that

the

abov

e-na

med

chi

ld h

as re

ceiv

ed th

e im

mun

izat

ions

indi

cate

d. In

ord

er to

rem

ain

enro

lled

this

chi

ld m

ust r

ecei

ve a

ll re

quire

d va

ccin

es w

ithin

18

mon

ths

from

initi

al e

nrol

lmen

t dat

e.

Sign

atur

e of

Phy

sici

an/N

urse

Pra

ctitio

ner/P

hysi

cian

Ass

ista

nt/P

ublic

Clin

ic

Dat

e

SIG

NAT

UR

E(S)

Not

ary

Pub

lic S

tam

pM

inne

sota

Imm

uniz

atio

n P

rogr

am: 6

51-2

01-5

503

or 1

-800

-657

-397

0 (M

DH

, 8/2

011)

C.Fo

r chi

ldre

n w

ho h

ave

a hi

stor

y of

dis

ease

or a

re m

edic

ally

exe

mpt

from

vac

cine

(s):

Th

e fo

llow

ing

imm

uniz

atio

n(s)

are

not

indi

cate

d be

caus

e of

med

ical

reas

ons,

his

tory

of d

isea

se, o

r (S

ee b

elow

for v

aric

ella

dis

ease

.) __

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

____

Sign

atur

e of

Phy

sici

an/N

urse

Pra

ctitio

ner/P

hysi

cian

Ass

ista

nt

Dat

e

Star

ting

Sept

embe

r 201

0 (B

efor

e Se

ptem

ber 2

010,

a p

aren

t can

sig

n.):

For c

hild

ren

who

are

18

mon

ths

or o

lder

who

hav

e a

hist

ory

of v

aric

ella

dis

ease

: I c

ertif

y th

at v

aric

ella

imm

uniz

atio

n is

not

indi

cate

d fo

r the

abo

ve-n

amed

chi

ld d

ue to

a h

isto

ry o

f va

ricel

la d

isea

se th

at I

have

dia

gnos

ed o

r had

ade

quat

ely

desc

ribed

to m

e by

the

pare

nt to

indi

cate

pa

st v

aric

ella

infe

ctio

n in

___

____

__.

ye

ar

Sign

atur

e of

Phy

sici

an/N

urse

Pra

ctitio

ner/P

hysi

cian

Ass

ista

nt (B

efor

e Se

ptem

ber 2

010,

a p

aren

t can

sig

n.)

Dat

e

Sig

natu

re o

f not

ary

publ

ic

Sub

scrib

ed a

nd s

wor

n to

bef

ore

me

this

___

____

__ d

ay o

f __

____

____

____

____

__, 2

0 __

____

____

.

Available on the web at: www.health.state.mn.us/divs/idepc/immunize/laws/childcareimzrec.pdf


Chi

ld C

are

Imm

uniz

atio

n R

ecor

d - I

nstr

uctio

nsbe

fore

a c

hild

atte

nds

child

car

e.W

ho s

houl

d co

mpl

ete

and

sign

this

form

?W

ho s

igns

dep

ends

on

the

child

’s a

ge a

nd s

ituat

ion.

Eith

er th

e pa

rent

/gua

rdia

n,

hi

stor

y.If

the

child

is a

t lea

st 1

5 m

onth

s ol

d an

d ha

s ha

d al

l the

sho

ts re

quire

d by

law,

a

pare

nt o

r gua

rdia

n ca

n si

gn th

e fo

rm in

Sec

tion

A.If

the

child

is y

oung

er th

an 1

5 m

onth

s or

has

not

had

all

the

shot

s re

quire

d by

law,

th

en a

hea

lth c

are

prov

ider

mus

t sig

n in

Sec

tion

B, s

ayin

g th

e ch

ild h

as b

egun

the

requ

ired

shot

s or

can

’t fo

r med

ical

reas

ons.

Star

ting

in S

epte

mbe

r 201

0, if

the

child

is 1

8 m

onth

s or

old

er a

nd h

as h

ad

varic

ella

dis

ease

(chi

cken

pox)

, a h

ealth

car

e pr

ovid

er m

ust s

ign

in S

ectio

n C

. (B

efor

e Se

ptem

ber 2

010,

a p

aren

t can

sig

n.)

If a

pare

nt o

r gua

rdia

n ob

ject

s to

a c

erta

in s

hot o

r all

shot

s, th

e pa

rent

or

guar

dian

mus

t com

plet

e Se

ctio

n D

and

hav

e it

nota

rized

by

a no

tary

pub

lic.

Not

es fo

r Par

ents

1. G

ive

your

chi

ld’s

imm

uniz

atio

n hi

stor

y to

the

child

car

e pr

ovid

er w

hen

you

enro

ll.M

inne

sota

law

(Min

n. S

tat.1

21A.

15) r

equi

res

child

ren

enro

lled

in a

Min

neso

ta

child

car

e to

be

imm

uniz

ed a

gain

st c

erta

in d

isea

ses

or h

ave

a le

gal e

xem

ptio

n.

This

form

is d

esig

ned

to p

rovi

de th

e ch

ild c

are

prov

ider

with

the

info

rmat

ion

re-

quire

d by

law.

Thi

s or

ano

ther

form

doc

umen

ting

imm

uniz

atio

ns o

r an

exem

ptio

n

are

an a

llow

able

form

.2.

Kee

p tr

ack

of y

our c

hild

’s s

hots

, and

tell

your

chi

ld c

are

prov

ider

eac

h tim

e yo

ur c

hild

get

s a

shot

.It

will

save

you

tim

e if

you

keep

a s

hot r

ecor

d fo

r eac

h of

you

r chi

ldre

n. B

e su

re

to h

ave

the

reco

rd u

pdat

ed e

ach

time

your

chi

ld re

ceiv

es a

sho

t.

also

nee

d th

is re

cord

for s

choo

l, ca

mp,

col

lege

, and

if y

ou g

o to

a n

ew d

octo

r or

clin

ic.

3. I

f you

r chi

ld is

not

up

to d

ate

on h

is o

r her

sho

ts, y

ou c

an c

atch

up.

By

law

you

hav

e 18

mon

ths

afte

r enr

ollin

g fo

r you

r chi

ld to

hav

e al

l his

or h

er

Min

neso

ta c

hild

ren

are

still

getti

ng d

isea

ses

like

mea

sles

, mum

ps, a

nd ru

bella

. Th

ese

dise

ases

are

con

tagi

ous.

The

y ca

n sp

read

rapi

dly—

espe

cial

ly a

mon

g gr

oups

of c

hild

ren

who

hav

e no

t rec

eive

d th

eir s

hots

. And

som

e of

them

, lik

e pe

rtuss

is (w

hoop

ing

coug

h), a

re m

uch

mor

e se

rious

for c

hild

ren

than

they

are

fo

r adu

lts. A

s a

pare

nt, y

ou c

an p

rote

ct y

our c

hild

ren

by m

akin

g su

re th

ey g

et a

ll th

eir s

hots

. Mos

t sho

ts a

re d

ue b

y 2

year

s of

age

.4.

If y

our c

hild

has

had

chi

cken

pox,

he

or s

he d

oes

not n

eed

a va

ricel

la s

hot.

But s

tarti

ng in

Sep

tem

ber 2

010,

if th

e ch

ild is

18

mon

ths

or o

lder

and

has

had

va

ricel

la d

isea

se (c

hick

enpo

x), a

hea

lth c

are

prov

ider

mus

t sig

n in

Sec

tion

C.

(Bef

ore

Sept

embe

r 201

0, a

par

ent c

an s

ign.

)

Not

es fo

r Chi

ld C

are

Prov

ider

s1.

mon

ths

of a

ge a

nd o

lder

.W

hen

the

prov

ider

GIV

ES p

aren

ts im

mun

izat

ion

info

rmat

ion

abou

t enr

ollm

ent f

or

child

car

e, th

e pr

ovid

er m

ust u

se th

is fo

rm o

r a s

imila

r for

m a

ppro

ved

by M

DH

as

requ

ired

by la

w.H

owev

er, t

he re

cord

that

is

that

doc

umen

ts im

mun

izat

ions

or a

n

a re

port

prin

ted

off o

f MIIC

(the

sta

te im

mun

izat

ion

regi

stry

) or a

noth

er e

lect

roni

c

a ch

ild e

nrol

ls a

t a y

oung

er a

ge, y

ou m

ust o

btai

n im

mun

izat

ion

info

rmat

ion

whe

n th

ey re

ach

2 m

onth

s of

age

.2.

Kee

p tr

ack

of th

e da

te w

hen

each

chi

ld’s

requ

ired

imm

uniz

atio

ns a

re d

ue

by la

w.

If a

child

is 2

mon

ths

of a

ge o

r old

er a

nd h

as n

ot y

et re

ceiv

ed a

ll th

eir r

equi

red

shot

s, y

ou s

houl

d no

te th

e da

te w

hen

thes

e im

mun

izat

ions

will

be d

ue b

y la

w: 1

8 m

onth

s af

ter t

he c

hild

enr

olls

in y

our f

acilit

y.U

nles

s th

ey a

re o

ther

wis

e ex

empt

, Min

neso

ta la

w re

quire

s pr

esch

oole

rs in

chi

ld

care

to h

ave

shot

s fo

r DTP

, pol

io, M

MR

, PC

V, H

ib, a

nd v

aric

ella

. If t

he c

hild

has

ha

d ch

icke

npox

dis

ease

, he

or s

he d

oes

not n

eed

a va

ricel

la s

hot,

but s

tarti

ng in

Se

ptem

ber 2

010,

they

mus

t hav

e a

heal

th c

are

prov

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Available on the web at: www.health.state.mn.us/divs/idepc/immunize/laws/childcareimzrec.pdf


Available on the web at: www.health.state.mn.us/divs/idepc/immunize/pupilimzrec.pdf

Pupil Immunization Record FOR SCHOOL USE ONLY( ) Complete; booster required in ___________( ) In process; 8 mos. expires _____________( ) Medical exemption for _________________( ) Conscientious objection for _____________( ) Parental/guardian consent _____________

Minnesota law requires children enrolled in school to be immunized against certain diseases or fi le a legal medical or conscientious exemption (see back for exemption information).Parent: Enter the MONTH, DAY, and YEAR for all vaccines your child received. DO NOT USE (9) or (). Vaccines/doses in shaded boxes are recommended but not required by law.School Personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it. Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space.

Type of Vaccine 1st DoseMo/Day/Yr

2nd DoseMo/Day/Yr

3rd DoseMo/Day/Yr

4th DoseMo/Day/Yr

5th DoseMo/Day/Yr

Diphtheria, Tetanus, and Pertussis (DTap, DTP)

Diphtheria and Tetanus (DT) • for 6-year-olds and younger

Tetanus and Diphtheria (Tdap, Td) • for 7-year-olds and older

Polio (IPV, OPV)

Measles, Mumps, and Rubella (MMR)• minimum age: on or after 1st birthday • required for kindergarten and 7th grade

Hepatitis B (hep B)• required for kindergarten and 7th grade

Varicella (chickenpox)• minimum age: on or after 1st birthday • vaccine or disease history required for kindergarten

and 7th grade

Haemophilus infl uenza type b (Hib)

Meningococcal (MCV, MPSV)

Human Papillomavirus (HPV)

Hepatitis A (hep A)

Developed by the Minnesota Department of Health - Immunization Program (5/11) #140-0155www.health.state.mn.us/immunize Page 1 of 2

Student Name _________________________________________________

Birthdate _____________________Student Number __________________

1. Choose one of the following to indicate student’s immunization status and the source of the information above:A. I certify that this student has received all immunizations required by law.

____________________________________________________________________________________________Signature of parent/guardian or physician/public clinic Date

B. I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B (K and 7th), varicella (K and 7th), measles, mumps, and rubella and will complete his/her diphtheria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months. The dates on which the remaining doses are to be given are:

____________________________________________________________________________________________

____________________________________________________________________________________________Signature of physician/public clinic Date

–OVER–


2. Parental/Guardian Consent: Your child’s school is asking your permission to share your child’s immunization record with Minnesota’s immunization registry to help us better protect students from disease. You are not required to sign this consent; it is voluntary. In addition, all the information you provide is legally classifi ed as private data and can only be released to those legally authorized to receive it under Minnesota law.

I agree to allow school personnel to share my student’s immunization record with Minnesota’s immunization registry:

______________________________________________________________________________________________Signature of parent or legal guardian Date

Developed by the Minnesota Department of Health - Immunization Program (5/11) #140-0155www.health.state.mn.us/immunize Page 2 of 2

3. Exemptions to School Immunization Law A. Medical exemption:

No student is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a student to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement:I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confi rmed. (For varicella disease see * below.)Exempted immunization(s):

____________________________________________________________________________________________

____________________________________________________________________________________________Signature of physician/nurse practitioner/physician assistant Date

*History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in ___________.

Year

___________________________________________________________________________________________Signature of physician/nurse practitioner/physician assistant

B. Conscientious exemption: No student is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the student or others they come in contact with. In a disease outbreak schools may exclude children who are not vaccinated in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized:I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s):

____________________________________________________________________________________________

____________________________________________________________________________________________Signature of parent or legal guardian Date

Subscribed and sworn to before me this _______ day of ______________________ 20______

___________________________________________________________Signature of notary

Additional exemptions:• Children less than 7 years of age: The 5th dose of DTaP/DTP/DT (similarly, the 4th dose of polio vaccine) is not

necessary if the 4th DTaP/DTP/DT (3rd dose of polio) was administered after the 4th birthday.• Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the

minimum requirements of the law.• Students in grades 7-12: A Td or Tdap booster at age 11 years or later is not required for students in grades 7-12 whose

most recent Td was given after their 7th birthday but before their 11th birthday. Instead, it will be required 10 years after the date of the most recent dose.

• Students 11-15 years of age: A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the alternative 2-dose schedule.

• Students 10 years or older: May receive Tdap to fulfi ll the Td requirement for students in grades 7-12.• Students 18 years of age or older: Do not need polio vaccine.


Data Elements Used in Recording Selected Childhood and Adult VaccinesVaccine Generic Name and Abbreviation Vaccine Brand Name MVX

codeCPT code

CVX code

Diphtheria, tetanus, pertussis (DTaP)

Daptacel PMC 90700 106Infanrix SKB 90700 20

Diphtheria, tetanus (pediatric) (DT) Generic PMC 90702 28DTaP–HepB–IPV Pediarix SKB 90723 110DTaP–IPV Kinrix SKB 90696 130DTaP–IPV–Hib Pentacel PMC 90698 120Tetanus, diphtheria (Td)

Decavac PMC 90714 113Generic MBL 90714 113

Tetanus, diphtheria, pertussis (Tdap)

Boostrix SKB 90715 115Adacel PMC 90715 115

Haemophilus influenzae type B (Hib)

PedvaxHIB (PRP-OMP) MSD 90647 49ActHIB (PRP-T) PMC 90648 48Hiberix (PRP-T) SKB 90648 48

Hib–HepB Comvax MSD 90748 51

Hepatitis A (HepA)

PediatricHavrix SKB 90633 83VAQTA MSD 90633 83

AdultHavrix SKB 90632 52VAQTA MSD 90632 52

Hepatitis B (HepB)

PediatricEngerix-B SKB 90744 8Recombivax HB MSD 90744 8

AdultEngerix-B SKB 90746 43Recombivax HB MSD 90746 43

HepA–HepB Twinrix SKB 90636 104

Human papillomavirus (HPV2, HPV4)

Gardasil, HPV4 (Types 6, 11, 16, 18) MSD 90649 62

Cervarix HPV2 (Types 16, 18) SKB 90650 118

Inactivated polio (IPV) IPOL PMC 90713 10

Influenza, trivalent inactivated influenza (TIV)

6-35 monthsFluzone PMC 90657 141Fluzone p-free PMC 90655 140

3 years or older

Fluzone PMC 90658 141Fluzone p-free PMC 90656 140Fluarix SKB 90656 140

4 years or older

Fluvirin NOV 90658 141Fluvirin p-free PMC 90656 140

9 years or older

Afluria CSL 90658 141Afluria p-free PMC 90656 140

18 years or older

FluLaval SKB 90658 141Agriflu PMC 90656 140

65 years or older

Fluzone high-dose PMC 90662 135

Continued199July 2011, Minnesota Department of Health Got Your Shots? Providers Guide - DOCUMENTING SHOTS www.health.state.mn.us/immunize

Data Elements Used in Recording Selected Childhood and Adult VaccinesVaccine Generic Name Vaccine Brand Name MVX

codeCPT code

CVX code

Influenza, live attenuated influenza vaccine (LAIV)

Flumist MED 90660 111

Japanese Encephalitis (JE) Ixiaro INT 90738 134Measles, mumps, rubella (MMR) M-M-R II MSD 90707 3

Measles, mumps, rubella, varicella (MMRV) ProQuad MSD 90710 94

Meningococcal conjugate (MCV)

Menactra PMC 90734 114Menveo NOV 90734 136

Meningococcal polysaccharide (MPSV) Menomune PMC 90733 32

Pneumococcal Conjugate, 7-valent (PCV) Prevnar PFR 90669 100

Pneumococcal Conjugate, 13-valent (PCV)

Prevnar PFR 90670 133

Pneumococcal, polysaccharide, 23-valent(PPSV)

Pneumovax23 MSD 90732 33

RabiesImovax PMC 90675 18

RabAvert NOV 90675 18

Rotavirus(RV1, RV5)

Rotarix (RV1) SKB 90681 119RotaTeq (RV5) MSD 90680 116

TyphoidTyphim Vi PMC 90691 101

Vivotif BPC 90690 25Varicella (chickenpox)(VAR) Varivax MSD 90716 21

Yellow Fever YF-VAX PMC 90717 37(ZOS) Zoster (shingles) Zostavax MSD 90736 121

This list includes the most commonly used vaccines. A current and comprehensive list of vaccines and their MVX, CPT, and CVX codes is available on the web at: www.health.state.mn.us/divs/idepc/immunize/registry/hp/vaxcodes.html.


Available on the web at: www.health.state.mn.us/divs/idepc/immunize/registry/hp/vaxcodes.html#mvx

Vaccine Manufacturers for Selected Childhood and Adult VaccinesMVX Code Vaccine Manufacturers

BPC Berna Products Corporation

CSL CSL Biotherapies, Inc.

MBL Massachusetts Biologic Laboratories (formerly Massachusetts Public Health Biologic Laboratories)

MED MedImmune, Inc.

MSD Merck & Co., Inc.

NOV Novartis Pharmaceutical Corporation (includes Chiron, PowderJect Pharmaceuticals, Celltech Medeva Vaccines and Evans Limited, Ciba-Geigy Limited, and Sandoz Limited)

PFR Pfizer, Inc

PMC sanofi pasteur (formerly Aventis Pasteur, Pasteur Merieux Connaught; includes Connaught Labo-ratories and Pasteur Merieux)

SKB GlaxoSmithKline (formerly SmithKline Beecham; includes SmithKline Beecham and Glaxo Wel-come)


Documents

Documenting Shots - health.state.mn.us€¦ · This section is filled with tips and tools to make documenting shots a more accurate, less complicated task. Overview of this section: