Vaccine Administration (Pharmacist Use ONLY)
I hereby certify that I have verified the screening questionnaire and consent with the above named patient
Vaccine: _______________ Dose: ______ Lot # : __________ Exp Date: __________ Manufacture:__________
Injection Site: Left Arm / Right Arm Route: IM
VIS Date of Publication:__________
Did an Adverse Reaction occur? Yes No
Contacted VAERS 800-822-7967 Date/Time:
Primary Care Physician contacted: Yes No
________________ _______________ ___________
Pharmacist Name Signature Date
NJIIS Uploaded by: Ins. Billed by: