PROVIDER INFORMATION Vaccine Provider: Clinic Site: Community Health Services Street Address: State Zip Code Street Address: State Zip Code 1004 Main Street KS 66534 (Circle the appropriate vaccine, dose, extremity, site, route, and enter the manufacturer, lot #, and expiration date) FOR CLINICAL USE ONLY Exp. Mfr./Lot # Vaccine Dose Ext. Site Route VIS Date Date Sanofi Pasteur IM 05/10/15 U5024BA (High Dose) 0.25ml 05/24/15 U5044BA (High Dose) Private 0.50ml 06/30/15 U5010FA (0.25ml PFS) RT Inventory Deltoid 1 2 UI188AB (0.5ml PFS) Vastus Lat 08/19/2014 Influenza UI196AE (MDV) LT UI190AA (MDV) Intranasal 0.2ml Med Immune 11/24/14 CF2182 (FluMist) VFC Inventory Sanofi Pasteur IM U5007AB (0.25ml PFS) Influenza RT 06/30/15 0.25ml UI191AB (0.5ml PFS) Deltoid 0.50ml 1 2 08/19/2014 Med Immune 12/08/14 Vastus Lat Intranasal CH2062 (FluMist) LT 0.2ml CHIP Inventory Sanofi Pasteur IM Influenza U5007AB (0.25ml PFS) RT 0.25ml Deltoid 06/30/15 1 2 08/19/2014 UI191AB (0.5ml PFS) 0.50ml LT Vastus Lat ________ Date Signature and Title of Vaccine Administrator
PROVIDER INFORMATION Vaccine Provider: Community Health Services Clinic Site: Street Address: 1004 Main Street State KS Zip Code 66534 Street Address: State Zip Code (Circle the appropriate vaccine, dose, extremity, site, route, and enter the manufacturer, lot #, and expiration date) FOR CLINICAL USE ONLY Vaccine Dose Ext. Site Route VIS Date Mfr./Lot # Exp. Date Private Inventory Influenza 1 2 RT LT Deltoid Vastus Lat IM 0.25ml 0.50ml Intranasal 0.2ml 08/19/2014 Sanofi Pasteur U5024BA (High Dose) U5044BA (High Dose) U5010FA (0.25ml PFS) UI188AB (0.5ml PFS) UI196AE (MDV) UI190AA (MDV) Med Immune CF2182 (FluMist) 05/10/15 05/24/15 06/30/15 11/24/14 VFC Inventory Influenza 1 2 RT LT Deltoid Vastus Lat IM 0.25ml 0.50ml Intranasal 0.2ml 08/19/2014 Sanofi Pasteur U5007AB (0.25ml PFS) UI191AB (0.5ml PFS) Med Immune CH2062 (FluMist) 06/30/15 12/08/14 CHIP Inventory Influenza 1 2 RT LT Deltoid Vastus Lat IM 0.25ml 0.50ml 08/19/2014 Sanofi Pasteur U5007AB (0.25ml PFS) UI191AB (0.5ml PFS) 06/30/15 ________ Signature and Title of Vaccine Administrator Date