DAILY USAGE LOG VACCINE FOR CHILDREN (VFC) PROGRAM
Date:
Ordering Period: __/__/__ to __/__/__
INSTRUCTIONS: Keep this log where you store vaccines. Fill in patient info and add a check mark for each vaccine you remove and administer today. At the end of the day, add the number of checks for each vaccine for your Daily Total. When you are ready to order vaccine, add all the Daily Totals for the Order Period Total and fill in as doses administered on your vaccine order. Keep logs for your own records. DTaP
Patient Name
Date of
(or medical record)
Birth
DTaP/ Hep B/ IPV
DTaP/ Hib/IPV
Hep B
Hep B/ Hib
Infanrix RECOMDAPTA- Pediarix Pentacel BIVAX Comvax CEL ENGERIX B
Hib
IPV
PCV
ActHIB PedvaxHIB
IPOL
Prevnar
Rotavirus
Hep A
Rotarix RotaTeq
VAQTA Havrix
DTaP/ IPV
Kinrix
HPV
MCV4
Td
Gardasil Menac- Tenivac Cervarix tra Menveo
Tdap
Varicella MMR
MMR-V
BOOSTRIX ADACEL
VARIVAX MMR-II
Proquad
Daily Total:
Order Period Total: Log taken by:
PAGE
OF
IMM-1053 (3/14)
DAILY USAGE LOG PRIVATE VACCINE
Date:
Ordering Period: __/__/__ to __/__/__
INSTRUCTIONS: Keep this log where you store vaccines. Fill in patient info and add a check mark for each vaccine you remove and administer today. At the end of the day, add the number of checks for each vaccine for your Daily Total. When you are ready to order vaccine, add all the Daily Totals for the Order Period Total and fill in as doses administered on your vaccine order. Keep logs for your own records. DTaP
Patient Name
Date of
(or medical record)
Birth
DTaP/ Hep B/ IPV
DTaP/ Hib/IPV
Hep B
Hep B/ Hib
Infanrix RECOMDAPTA- Pediarix Pentacel BIVAX Comvax CEL ENGERIX B
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