AL ADPH-IMM-66 2003 free printable template

Alabama Department of Public Health Vaccine Administration Form THIS FORM MUST BE FILLED IN COMPLETELY BEFORE WE CAN GIVE YOU A FLU SHOT PLEASE PRINT Last Name First Name Group Date of Birth Contract MI Age Street Address City County State Zip Code I give permission for my child or myself to receive the vaccine indicated. I authorize payment for the vaccine provided. I have received notice of my privacy rights and I have been given or offered a c...

How to fill out AL ADPH-IMM-66

How to fill out AL ADPH-IMM-66

1. Begin by downloading the AL ADPH-IMM-66 form from the Alabama Department of Public Health website.
2. Fill in your personal information at the top of the form, including your name, address, date of birth, and contact information.
3. Indicate the type of immunization you are requesting or reporting by checking the appropriate box.
4. Provide details about the immunization, including the date it was given, the vaccine type, and the administering provider's information.
5. If applicable, include information for any additional vaccines by repeating the previous two steps for each immunization.
6. Review the completed form for accuracy and completeness before submission.
7. Submit the form via the specified method on the instructions, whether by mail, email, or online submission.

Who needs AL ADPH-IMM-66?

1. Individuals who have received immunizations and need to document them for school, work, or other requirements.
2. Healthcare providers who are required to report immunizations administered to patients.
3. Parents or guardians who need to keep track of their children's immunization records for school enrollment.

People Also Ask about

Is the flu vaccine an intramuscular injection?

The flu shot is usually given as an intramuscular (IM) needle injection into the upper, outer arm muscle called the deltoid muscle in people 3 years of age and older.

What is flu vaccine administration?

For adults 19 years of age and older, the deltoid muscle in the upper arm is the preferred site, although the vastus lateralis muscle in the anterolateral thigh may be used if the deltoid site cannot be used. Influenza vaccines are not highly viscous, so a fine-gauge (22- to 25-gauge) needle can be used.

What is the proper administration of the influenza vaccine?

Most flu shots are given in the arm (muscle) with a needle. Afluria Quadrivalent can be given either with a needle (for people 6 months and older) or with a jet injector (for people 18 through 64 years only).

What should be documented when administering a vaccine?

The following information must be documented on the patient's paper or electronic medical record or on a permanent office log: The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered. The name, office address, and title of the healthcare provider administering the vaccine.

How do you administer quadrivalent flu vaccine?

The preferred sites for intramuscular injection are the anterolateral aspect of the thigh in infants 6 months through 11 months of age, the anterolateral aspect of the thigh (or the deltoid muscle if muscle mass is adequate) in persons 12 months through 35 months of age, or the deltoid muscle in persons ≥36 months of

How do you document the administration of the flu vaccine?

Job Aid Date of administration. Vaccine manufacturer. Vaccine lot number. Name and title of the person who administered the vaccine and address of the facility where the permanent record will reside. Vaccine information statement (VIS) Date printed on the VIS. Date the VIS was given to the patient or parent/guardian.

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What is AL ADPH-IMM-66?

AL ADPH-IMM-66 is a form used by healthcare providers in Alabama to report immunization records for patients.

Who is required to file AL ADPH-IMM-66?

Healthcare providers who administer vaccines and maintain immunization records for patients are required to file AL ADPH-IMM-66.

How to fill out AL ADPH-IMM-66?

To fill out AL ADPH-IMM-66, providers must enter patient information, vaccination details, and submit the form as directed by the Alabama Department of Public Health.

What is the purpose of AL ADPH-IMM-66?

The purpose of AL ADPH-IMM-66 is to ensure accurate tracking of immunization records and to promote public health in Alabama.

What information must be reported on AL ADPH-IMM-66?

The information that must be reported on AL ADPH-IMM-66 includes patient identification details, vaccine type, administration date, and provider information.