Free F-44702S - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health DPH 4702S (Rev. 03/07)

STATE OF WISCONSIN Wis. Stats. 252.04

REGISTRO DE ADMINISTRACIÓN DE VACUNAS

This form has been renumbered and revised. Please update your link to the following: http://dhs.wisconsin.gov/forms/F4/F44702s.pdf

DPH 4702S (Rev. 03/07) Pagina 2 Nombre del Paciente (Apellido, Primer Nombre y Inicial) For Office Use Only (PARA USO DE OFICINA) Vaccine Route Site Admin.* DTaP/DT Dtap-Hep B-IPV Combined Hep A Hep B Hib Hib-Hep B Combined HPV (Human papillomavirus) Influenza Meningococcal Conjugate (MCV4) MMR MMR-V Pneumococcal Conjugate (PCV7) Polio Rotavirus Td Tdap Varicella Other IM IM IM IM IM IM IM IN** IM IM SQ SQ IM IM or SQ Oral IM IM SQ RV LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD
**IN = Intranasal

Dose Number 1 2 3 4 5 1 2 3 4 1 2 1 2 3 1 2 3 4 1 2 3 1 2 3 1 2

Manufacturer

Lot Number 07/30/01

CDC Form Date

RV LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD

Use dates from DtaP, Hep B, Polio 03/21/06 07/11/01 12/16/98 Use dates from Hib and Hep B 09/05/06 ­ Okay to use per CDC OR 02/02/07 Use latest Vaccine Info. Statement

RV LV RD LD Rv LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD RV LV RD LD

1 2 1 1 2 1 2 1 2 3 4 1 2 3 4 1 2 3 1 2 3 4 5 6 1 1 2 10/07/05 (Interim) This version is not current 01/15/03 Use dates from MMR & Varicella 09/30/02 01/01/00 04/12/06 (Interim) 06/10/94 07/12/06 (Interim) 01/10/07

*RV=R Vastus Lateralis, LV=L Vastus Lateralis, RD=R Deltoid, LD=L Deltoid Subcutaneous injections are administered in the muscle "area".

SIGNATURE AND TITLE ­ Person Administering Vaccine X Address ­ Clinic, Public Health Department: Comments:

Date Vaccine Administered