Patient Identifier* FirstNameLastNameBirthdate (ie. SteveJohnson01201928)Section AComplete BEFORE vaccine administration1. I have reviewed the Patient Information and Screening Questions.* Initial here:2. I have verified that this is the vaccine requested by the patient.* Initial here:3. This vaccine is appropriate for this patient based on the Age Guidelines provided by federal and/or state regulations and company policies.* Initial here:4. Does this patient have a high-risk medical condition? Yes No 4a. If yes, please list medical condition(s): 5. The Vaccine NDC matches the NDC on the bottom of this VAR form and the NDC on the patient leaflet. (Perform 3-way NDC match.)* Initial here:6. I have verified the Expiration Date is greater than today’s date and have entered the Lot # and Expiration Date in the field below.* Initial here:For Shingrix®, Zostavax®, MMR® II, Varivax®, YF-Vax®, Menveo®, Imovax®, Vaxchora® and RabAvert®, ensure the vaccine is reconstituted following the package insert’s instructions.Lot #* Expiration Date* For vaccines that have a diluent or buffer, complete the following:Lot # Expiration Date Section BComplete DURING the patient interaction1. I have asked the patient to confirm their Name, DOB and Requested Vaccine and verified it matches the information on the VAR form.* Initial here:2. I have reviewed the Screening Questions with the patient.* Initial here:3. I have reviewed the VIS with the patient.* Initial here:Section CComplete AFTER vaccine administrationVaccine* NDC* Manufacturer* Dosage* Site of administration* VIS published date* Clinician Name* First Last Clinician Title* If applicable, intern/tech name First Last Administration Date* DD slash MM slash YYYY Date VIS Given To Patient* DD slash MM slash YYYY NotesClinician Signature*
