Model Standing Orders

The physician responsible for an immunization clinic must sign model standing orders. The signing physician (or someone covering for the signing physician) must be accessible to clinic staff by telephone or in person on the day(s) of the clinic. Nurses can then administer vaccine to patients who present to the clinic. The physician responsible for the clinic should also sign Model Standing Orders for Emergency Treatment so that nurses can respond to and treat adverse events that rarely occur following vaccination.

The Massachusetts Department of Public Health (MDPH) Hepatitis A Model Standing Orders contain indications for hepatitis A vaccination, the medical order, contraindications to hepatitis A vaccine, the hepatitis A immunization schedule, and special circumstances for vaccination (e.g., travel).

MDPH's General Protocols for Standing Orders contain detailed information regarding requirements for administration of all vaccines (i.e., vaccination requirements for persons administering vaccines, screening patients prior to vaccination, patient education requirements, consent requirements when a parent or legal representative is not present at the time of vaccination, vaccine storage and handling, general administration guidelines, documentation requirements, and post-vaccination adverse event reporting) and recommendations for drawing up vaccines in the mass vaccination clinic setting (i.e., viability of the vaccine, ability to identify vaccines in the syringe, and avoiding vaccine wastage).

Model Standing Orders for Emergency Treatment pdf format of Emergency Treatment for Vaccine Reactions (Model Standi
(PDF) | RTF rtf format of Emergency Treatment for Vaccine Reactions (Model Standi
MDPH's Emergency Treatment Model Standing Orders contain guidance for treatment of syncope, local reactions to vaccination, and mild and severe symptoms of anaphylaxis.

Please remember that these standing orders serve as models and may be adapted to the specific needs of your clinical setting.


Vaccine Adverse Event Reporting System (VAERS) -
The VAERS program is a post-marketing safety and surveillance collaboration between the Centers for Disease Control and Prevention and the Food and Drug Administration. Information about adverse events and side effects that occur after the administration of US licensed vaccines should be reported to VAERS. VAERS reports may be completed electronically through the VAERS website or by mail (the paper form is available on the VAERS website or at MDPH, 617-983-6800).

Vaccine Administration Record (VAR)
Vaccine Administration Records from the Massachusetts Department of Public Health include all of the fields required for proper documentation of vaccine administration in accordance with the and MDPH recommendations. The following VARs are specific for immunization clinics, children and adolescents, and adults.
  • Immunization Clinic VAR (RTF) rtf format of record-vaccine-admin.rtf
    The Immunization Clinic VAR can be used in a mass vaccination clinic setting to record immunizations for multiple patients on a single page.

Sample Provider Notification Letter (RTF) rtf format of Sample Provider Notification Letter
br>The Provider Notification Letter is a sample of a letter that should be given to patients who are vaccinated in a mass clinic setting. Patients can then notify their primary care provider about vaccine(s) received at the clinic by mailing them the letter or giving it to them at their next appointment.

Additional documentation materials including the Adult Immunization Record, the Lifetime Health and Vaccination Record (the "Blue Book") and the Hepatitis A Vaccination Card can be requested from the Massachusetts Department of Public Health, Division of Epidemiology and Immunization by calling 617-983-6800.

Hepatitis A Vaccine Screening Tool (PDF) pdf format of mso-hepa-screening.pdf
This tool serves as a questionnaire that will help health care workers determine patient eligibility for a hepatitis A vaccination.

Vaccine Order Form and Guidelines

Please use this order form to request doses of hepatitis A vaccine. This form may be returned by fax or general mail. Please call the MDPH Vaccine Management Unit at 617-983-6828 with any additional questions.

The Hepatitis A Vaccine Guidelines include information on vaccine eligibility, ordering, administration and accountability.

This information is provided by Epidemiology Program within the Department of Public Health.