Immunization Branch

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DTaP

$ 9.00

$27.00

MMR (includes 2nd dose)

$14.20

$26.00

IPV

$ 3.03

$ 5.45

H. INFLUENZAE TYPE b

$ 3.40

$ 5.40

HEPATITIS B

PERINATAL

INFANT

ADOLESCENT

$1.40

$0.90

$0.50

$14.70

$5.10

$3.80

VARICELLA

$ 0.90

$ 5.40

Name and, if appropriate title of the health care provider who administers the vaccine

Address where vaccine given (in the case of outreach clinics, address should be the clinic site where the record will reside)

Date of vaccination

Manufacturer and lot number of vaccine

1986 National Childhood Vaccine Injury Act (NCVIA) 42 U.S.C. § 300aa-25

Edition (date of publication) of Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS)^* provided and date provided.

1994 amendment to 42 U.S.C. Sec. 2125. § 300aa-25

Site and route of administration

Not required, but recommended. Information requested for reports to Vaccine Adverse Event Report System (VAERS).

Bacillus Clamette-Guerin Vaccine

1921

Diphtheria Toxoid

1926

Tetanus Toxoid

1933

Tetanus and Diphtheria Combined Toxoid

1934

Influenza Vaccine

1945

Pertussis Vaccine

1949

Tetanus, Diphtheria Toxoid and Pertussis Vaccine

1949

Mumps Vaccine, inactivated

1950

Inactivated Poliomyelitis Vaccine (Salk)

1955

Oral Poliomyelitis Vaccine (Sabin)

1961

Trivalent Oral Polio Vaccine

1963

Measles Vaccine, live

1963

Measles Vaccine, inactivated

1963

Mumps Vaccine, live

1967

Rubella Vaccine, live

1969

Measles-Rubella Combined Vaccine, live

1971

Measles-Mumps-Rubella Vaccine, live

1971

Pneumococcal Vaccine (14-valent)

1977

Human Diploid Cell Vaccine (Rabies Vaccine)

6/80

Hepatitis B Vaccine

11/81

Pneumococcal Vaccine (23-valent)

1983

Haemophilus influenzae Type b Polysaccharide Vac.

4/85

Enhanced-Inactivated Poliomyelitis Vaccine

11/85

Hepatitis B Vaccine (RECOMBIVAX HB®)

7/86

IPOL^TM

Poliovax^TM

1987

Haemophilus influenzae Type b Conjugate Vaccine

12/87

Diphtheria-Tetanus-Pertussis (Acellular) Vaccine

12/17/91 (Lederle)

8/21/92 (Connaught)

Diptheria-Tetanus-Pertusis Haemophilus influenzae Type b Conjugate Combination Vaccine

3/30/93
11/93 (2nd product)

Hepatitis A Vaccine - 3 dose schedule (SmithKline Beecham)

2/95

Varicella Vaccine

3/17/95

Hepatitis A Vaccine - 2 dose schedule (Merck Vaccine Division)

3/29/96

Diphtheria-Tetanus-Pertussis (Acellular) Vaccine for infants

7/31/96 (Connaught)

Diphtheria-Tetanus-Pertussis (Acellular)/ Haemophilus influenzae Type b Conjugate Combination Vaccine (4th dose at 15 to 18 months)

9/30/96

Haemophilus influenzae type b conjugate (Meningococcal Protein Conjugate) and Hepatitis B (Recombinant Vaccine) COMVAX

10/02/96

Diptheria & Tetanus Toxoids Adsorbed (Chiron Behring GmbH - with SKB)

1/29/97

Diphtheria-Tetanus-Acellular Pertussis (Infanrix) (Chiron Behring GmbH-with SKB)

1/29/97

Diphtheria & Tetanus Toxoids Adsorbed (Connaught Labs. Ltd) (Children, 6 weeks to 7 years of age).

4/11/97

Rabies Vaccine (Chiron Behring GmbH-Germany)

10/97

Rotavirus Vaccine (Wyeth-Lederle: RotaShield)

8/31/98

Hepatitis B Vaccine - Merck - 5.0 mcg for ages 0-19 years old

8/98

Lyme Vaccine (SmithKline Beecham Biologicals: LYMErix)

12/21/98

Pneumococcal Conjugate Vaccine (Wyeth-Lederle: Prevnar^TM)

2/17/2000