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Last Updated: 22 Oct 09
   All Forms
 

General Vaccine
  Dosing Cards
 for Treatment of Children Exposed to Weapons of Mass Destruction - USPHS
  Initial Competency Assessment - Allergy / Immunizations & Travel Medicine PDF  07 Nov 05
  DiLorenzo TRICARE Health Clinic
  VAERS Form



Anthrax
  Army MEDCOM Regulations and AVA Immunization Record (Form 700-R) PDF  04 Sep 03
 MEDCOM form #700-R has been rescinded and is no longer to be used for recording anthrax vaccinations.
Please continue to record all vaccinations in the following places:
- Health Record Immunization Record - SF 601
- International Certification of Vaccination - PHS Form 731
- Adult Preventive and Chronic Care Flow-sheet - DD Form 2766 & DD Form 2766C
- Service automated immunization tracking system - MEDPROS/AFCITA/SAMS
  DoD AVIP Implementation Instructions   [DOC]  [PDF]  05 Aug 09
 Includes AVIP Registry Agreement
  Dosing Cards
 for Treatment of Children Exposed to Weapons of Mass Destruction - USPHS
  Education Roster - Post-EUA (template)   [PDF]  [XLS]  12 Jan 06
  Next Dose Scheduled Card PDF  26 May 05
 Anthrax Vaccine
  VAERS Form



Influenza - H1N1
  Adult Screening and Immunization Documentation Form PDF  28 Sep 09
 2009 H1N1 Influenza Monovalent Vaccination Program
  Injectable H1N1 Influenza Vaccine Administration Competency Assessment PDF  04 Oct 09
 Military Vaccine Agency
  Intranasal H1N1 Vaccine Administration Competency Assessment PDF  04 Oct 09
 Military Vaccine Agency
  Pediatric/Adolescent Screening and Immunization Documentation Form PDF  28 Sep 09
 2009 H1N1 Influenza Monovalent Vaccination Program
  Standing Order for the Administration of the H1N1 Influenza Vaccine to Adults 2009 PDF  14 Oct 09
 Military Vaccine Agency
  Standing Order for the Administration of the H1N1 Influenza Vaccine to Children and Adolescents 2009 PDF  14 Oct 09
 Military Vaccine Agency



Influenza - Seasonal
  Influenza Clinic Supply Checklist PDF  04 Aug 09
 Military Vaccine Agency
  Injectable Influenza Vaccine Administration Competency Assessment PDF  21 Jul 09
 Military Vaccine Agency
  Intranasal Influenza Vaccine Administration Competency Assessment PDF  21 Jul 09
 Military Vaccine Agency
  Screening and Immunization Documentation Form (Adult)  PDF  04 Aug 09
 2009-2010 Seasonal Influenza Vaccination Program
  Screening and Immunization Documentation Form (Pediatric/Adolescent ) PDF  04 Aug 09
 2009-2010 Seasonal Influenza Vaccination Program
  Standing Order for the Administration of the Influenza Vaccine to Adults 2009-2010 PDF  04 Aug 09
 Military Vaccine Agency
  Standing Order for the Administration of the Influenza Vaccine to Children and Adolescents 2009-2010 PDF  04 Aug 09
 Military Vaccine Agency



Smallpox
  30-day Diary Card PDF  07 Feb 08
 Symptom Diary After Smallpox Vaccination
  Continuation Page PDF  07 Feb 08
 Smallpox Vaccination Continuation Note CHRONOLOGICAL RECORD OF MEDICAL CARE
  Initial Competency Assessment: Smallpox Vaccine Administration PDF  07 Mar 08
 MILVAX Agency
  Initial Competency Assessment: Smallpox Vaccine Reconstitution PDF  07 Mar 08
 MILVAX Agency
  Medical Note for Follow-Up after Vaccination  PDF  23 Jul 08
 Follow-Up Note for Standard "Take-Check" Visits
  Medical Note for Follow-Up after Vaccination  PDF  23 Jul 08
 Follow-Up Note for Sick Call Evaluation of Patients [pre position this form at ERs and troop medical clinics]
  Medical Note for Screening for Contraindications  PDF  07 Apr 08
 2-page format, STANDARD FORMAT
  VAERS Form
  VAERS Pregnancy Supplement PDF  01 Mar 08
 Supplemental Form for Smallpox Vaccine in Pregnancy Registry


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