Ty for maintaining the federally required information is with the clinic that administered the vaccine. Be sure to place a ü in the “Given elsewhere” column. If a patient transfers to another clinic, provide a photocopy to the new clinic. Use the MIIC registry to record and find immunizations If you’re participating in the Minnesota Immunization Information Connection (MIIC), be sure to enter or submit data on new shots for this patient so it is available to others who may be giving subse.
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How to use or fill out the MN IC 140-0497 online
This guide provides a clear and supportive approach to filling out the MN IC 140-0497 form, also known as the Adult Immunization Record. By following the steps outlined here, users can ensure accurate and compliant documentation of immunization records.
Follow the steps to complete the MN IC 140-0497 form online.
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Start by entering the individual's last name, first name, and middle initial in the designated fields.
- Input the gender of the individual being recorded.
- Provide the clinic name and address in the appropriate section.
- Enter the date of birth clearly in the format of month/day/year, followed by the individual's mother's maiden name.
- Proceed to document the vaccines given by filling out the specific fields for each vaccine type. Indicate the vaccine name, the date given, type of vaccine, manufacturer, lot number, route of administration, dosage, and injection site.
- If applicable, check the box for a history of vaccine reaction. This is important for ensuring accurate medical history.
- Record the date the Vaccine Information Statement (VIS) was given to the vaccinee and the date on the bottom of the VIS.
- The vaccine administrator should sign and indicate their title in the specified field.
- Once all sections are completed, review the information for accuracy before saving your changes. You can then download, print, or share the completed form as needed.
Complete your documents online today to ensure accurate and efficient record keeping.
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