{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Sheet1","Instructions","Data Input","Form"],"not_rendered":{"charts":0,"images":3,"macros":1,"external_links":0,"defined_names":4,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Sheet1","index":0,"n_rows":80,"n_cols":11,"rows_kept":80,"cut":false,"hidden":true,"merged":[[9,8,9,10],[14,1,14,2],[14,6,14,8],[4,1,4,5],[4,7,4,10],[6,1,6,2],[6,8,6,10],[8,1,8,5],[8,7,8,10],[11,0,11,10],[12,0,12,10],[13,0,13,10],[64,0,64,1],[64,2,64,3],[64,7,64,8],[64,9,64,10],[67,8,67,9],[63,0,63,1],[63,2,63,3],[63,7,63,8],[63,9,63,10],[37,0,37,1],[38,0,38,1],[39,0,39,1],[40,0,40,1],[41,0,41,1],[37,2,37,3],[38,2,38,3],[39,2,39,3],[40,2,40,3],[37,4,37,5],[38,4,38,5],[39,4,39,5],[40,4,40,5],[37,7,37,10],[36,7,36,8],[36,9,36,10],[35,0,35,1],[35,2,35,3],[35,4,35,5],[36,0,36,1],[36,2,36,3],[36,4,36,5],[28,0,28,10],[16,0,16,9],[21,0,22,5],[25,0,26,5],[35,9,35,10],[35,7,35,8]]}
["Vaccine Administration Record (VAR)"]
["Informed Consent for Vaccination in Long Term Care Facility (LTCF)"]
[]
["SECTION A-1 Please print clearly."]
["First name: ",null,null,null,null,null,"Last name: "]
[]
["Date of birth: ",null,null,"Age: ",null,"Gender:","Female","Male       Phone:"," "]
[]
["LTCF Name: ",null,null,null,null,null,"Address:"]
["City: ",null,"State: ",null,"ZIP code: ",null,"Patient Email address: "]
["I want to receive the following vaccination(s): COVID-19 Vaccination"]
["SECTION A-2 I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where  the  patient  is not  otherwise  competent  or  unable  to  consent  for  themselves.  Further,  I hereby give my consent to Walgreens or Duane Reade and  the  licensed  healthcare  professional administering  the  vaccine,  as  applicable (each  an  “applicable Provider”), to administer the vaccine(s)) I have requested above. I understand that it is not possible to predict all possible side  effects  or complications associated with receiving vaccine(s). I  understand the risks and benefits associated with the above  vaccine(s)  and  have  received,  read  and/or  had  explained  to  me  the  EUA  Fact  Sheet  on  the  vaccine(s)  I  have elected  to receive. I also acknowledge that I  have  had  a  chance  to  ask  questions  and  that  such  questions  were  answered  to  my  satisfaction. Further, I acknowledge that I have been advised that the  patient  should  remain  near  the  vaccination  location  for  observation for approximately 15 minutes after administration.  On  behalf  of  the  patient,  the  patient’s  heirs  and  personal representatives, I hereby release and hold harmless each applicable Provider, its staff, agents,  successors,  divisions,  affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above."]
["I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, or to any state or federal governmental agencies or  authorities  (“Government Agencies”), such as state, county, or local Departments of Health or the federal Department of Health and Human Services, the Center for Disease Control and Prevention, or their respective  designees  as  may  be  required  by  law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s law, I may prevent, by using a state-approved opt-out  form  or,  as  permitted  by  my  state  law,  an  opt-out  form  (“Opt- Out Form”) furnished by the applicable Provider: (a) the disclosure of my vaccination information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and, to the extent required by my state’s law, by signing below, I hereby do consent to the applicable Provider reporting my vaccination information to the Government Agencies, State HIE, or through the State HIE and/or State Registry to the entities and for  the  purposes  described  in  this  Informed  Consent  form. Unless I provide the applicable Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the applicable Provider and/or my State HIE, as applicable."]
["I understand that even if I do not consent or if I withdraw my consent, my state’s laws or federal law may permit certain disclosures of my vaccination information to or through the State HIE or  to  Government  Agencies  as required or permitted by law. I further authorize     the applicable Provider to: (a) release my medical or  other  information,  including  any  communicable  disease  (including  HIV),  and mental health information, to, or through, the State  HIE  or  Government  Agencies  to  my  healthcare  professionals,  Medicare,  Medicaid, or other third-party payer as necessary to effectuate care or payment; (b) submit a claim to my insurer for the above requested items and services; and (c) request payment  of  authorized  benefits  be  made  on  my behalf  to  the  applicable  Provider  with  respect  to  the  above requested items and services. I further agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible  is  due  at  the  time  of  service  or,  if  the applicable Provider invoices me after the time of service, upon receipt of such invoice. Walgreens may  disclose  your  vaccination information from this visit for public health purposes  and  will  send  this  information  to  the  Medical  Director  or  Administrator  of  the  LTCF identified above. If you are an employee of the LTCF, Walgreens will send your vaccination information to your employer as required."]
["Print Name: ",null,null,"Patient/Authorized Person signature: ",null,null,null,null,null,"Date: "]
[]
[" SECTION B-1 SCREENING QUESTIONS. The following questions will help us determine your eligibility to be vaccinated today."]
[]
["1.     Do you feel sick today?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["2.     Do you have any health conditions, such as heart disease, diabetes or asthma?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["        'If yes, please list:  _______________________________________________________________________"]
["3.     Do you have allergies to latex, medications, food or vaccines (examples: eggs,         \n         bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or \n         thimerosal)?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
[]
["     'If yes, please list:  _______________________________________________________________________"]
["4.     Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["5.     Have you ever had a seizure disorder for which you are on seizure medication(s), \n       a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or \n       other nervous system problem?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
[]
["6.     For women: Are you pregnant or considering becoming pregnant in the next month?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["SECTION B-2 I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient or representative of; or (c) a representative of the LTCF and, based upon clinical observation, have sufficient knowledge of the patient’s condition to answer the Screening Questions. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction."]
[]
["Patient / LTCF Representative: __________________________________________________________________",null,null,null,null,null,null,null,"Date:_______________________"]
[]
[]
["Please ensure to record BOTH pharmacy AND medical insurance information since there are multiple ways immunizations can be billed at Walgreens."]
[]
["Non-Medicare:",null,"Pharmacy Card",null,"Medical Card",null,null,"Medicare:",null,"Medicare Part B"]
["Insurance Plan/Plan ID:",null,null,null,null,null,null,"Medicare Number:*"]
["Member/Recipient ID #",null,null,null,null,null,null,"*Medicare Claim Number for cards distributed earlier than 2018."]
["RX BIN:",null,null,null,"N/A"]
["RX PCN:",null,null,null,"N/A"]
["Group Number:"]
[]
["Is the patient the cardholder?",null,null,"Yes","No"]
["If no, please provide cardholders name, date of birth (MM/DD/YYY) and relationship: "]
[null,"INSURANCE – PATIENT TO COMPLETE IF APPLICABLE"]
[]
["Complete BEFORE vaccine administration"]
["1.   I have reviewed the Patient Information and Screening Questions.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["2.   I have verified that this is the vaccine requested by the patient.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["3.   This vaccine is appropriate for this patient based on the Age Guidelines and Other Guidelines provided by federal and/or",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["state regulations and company policies."]
["3a. Does this patient have a high-risk medical condition?",null,null,null,null,null,null,null,null,"Yes","No"]
["      If yes, please list medical condition(s):  ________________________________________________________________"]
["4.   The Vaccine NDC matches the NDC on the bottom of this VAR form and the NDC on the patient leaflet. (Perform 3-way NDC match.) ",null,null,null,null,null,null,null,null,"Initial here:","__________"]
["5.   I have verified the Expiration Date is greater than today’s date and have entered the Lot # and Expiration Date in the field below.",null,null,null,null,null,null,null,null,"Initial here:","__________"]
[]
[" SECTION E Complete DURING the patient interaction"]
["1.   I confirm(ed) the patient’s Name, DOB and Requested Vaccine and verified it matches the information on the VAR form.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["2.   I have reviewed the Screening Questions and answers.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["3.   I provided a EUA Fact Sheet to the patient or the LTCF representative.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
[]
[" SECTION F "]
["Complete AFTER vaccine administration"]
["Vaccine",null,"NDC",null,"Manufacturer","Dosage","Dose 1","Site of administration",null,"EUA Fact Sheet published date"]
[null,null,null,null,null,null,"Dose 2"]
[]
["Clinician’s name (print): ",null,null,null,null,"Clinician’s signature: ",null,null,"Title:"]
["If applicable, intern/tech name (print): ",null,null,null,null,"Administration date: ",null,null,"Date EUA Fact Sheet given to patient:   "]
[]
["COVID-19 VACCINE LOT# ",null,null,null,null,null,null,"COVID-19 VACCINE EXPIRATION DATE  "]
[]
[]
[]
[]
[]
[]
[]
[]
["1.      Update the patient’s record with any new allergy, health condition or primary care provider information."]
["2.      Enter vaccine lot #, expiration date and side of administartion, then scan the VAR form into the patient's record."]

{"sheet":"Instructions","index":1,"n_rows":40,"n_cols":3,"rows_kept":40,"cut":false,"hidden":false,"merged":[]}
[]
[null,"The purpose of this workbook is to help complete the Walgreens Vaccination Form for all Residents and Staff easily and efficiently"]
["Instructions:"]
[1,"Populate all columns on the \"Data Input\" tab with information from your staff and residents "]
[null,"Do not leave any cells blank"]
[null,"If the answer is N/A - put N/A"]
[]
[2,"Create a New Folder on your desktop and name it \"Walgreens Forms\""]
[null,null,"Do this by Right Clicking your desktop "]
[null,null,"Go to New"]
[null,null,"Click on Folder"]
[null,"See picture on right for instructions"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[3,"Copy the Address of the folder"]
[null,"To get Address - "]
[null,"Open the folder"]
[null,"Click the bar with the folder destination and copy the text"]
[null,"It should look similar to the highlighted address on right"]
[]
[]
[]
[4,"Open \"Form\" Tab"]
[5,"Click the big blue button that says \"RUN\""]
[6,"An Input box will appear asking for the address that was copied in step 3"]
[null,"Paste the address in the box"]
[]
[7,"Let the computer run its course, when the MACRO is complete the final name entered on the data tab will appear on the form"]
[8,"Go to the folder on your desktop and all Employees/Residents entered on the \"Data Input\" tab will be individually saved in PDF and complete"]
[]
[9,"NOTE: All checkboxes and Wet Signatures will need to be done manually by the employee/residents/representative"]
[]
[10,"Any questions feel free to call me - Abie Cooperberg - 516-672-9928"]

{"sheet":"Data Input","index":2,"n_rows":3,"n_cols":26,"rows_kept":3,"cut":false,"hidden":false,"merged":[[1,14,1,18],[1,19,1,21],[0,0,1,9],[0,10,1,11],[0,12,1,13],[0,14,0,22]]}
["Section A-1",null,null,null,null,null,null,null,null,null,"Section A-2",null,"Section B-2",null,"Section C",null,null,null,null,null,null,null,null,null,{"$f":"COUNTA(A4:A1048576)","v":0},"Created by: Abie Cooperberg"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Non Medicare: Pharmacy Card",null,null,null,null,"Non Medicare: Medical Card",null,null,"Medicare"]
["First Name","Last Name","Date of Birth","Phone","LTCF Name","Address","City","State","ZIP Code","Patient Email address","Print Name","Date","Patient/LTCF Representative","Date","Insurance Plan/Plan ID","Member/Recipient ID #","RX BIN ","RX PCN","Group Number","Insurance Plan/Plan ID","Member/Recipient ID #","Group Number","Medicare Number"]

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["Vaccine Administration Record (VAR)"]
["Informed Consent for Vaccination in Long Term Care Facility (LTCF)"]
[]
["SECTION A-1 Please print clearly."]
["First name: ",null,null,null,null,null,"Last name: "]
[]
["Date of birth: ",null,null,"Age: ",{"$f":"YEAR(TODAY())-YEAR(B7)","v":120},"Gender:","Female","Male       Phone:"]
[]
["LTCF Name: ",null,null,null,null,null,"Address:"]
["City: ",null,"State: ",null,"ZIP code: ",null,"Patient Email address: "]
["I want to receive the following vaccination(s): COVID-19 Vaccination"]
["SECTION A-2 I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where  the  patient  is not  otherwise  competent  or  unable  to  consent  for  themselves.  Further,  I hereby give my consent to Walgreens or Duane Reade and  the  licensed  healthcare  professional administering  the  vaccine,  as  applicable (each  an  “applicable Provider”), to administer the vaccine(s)) I have requested above. I understand that it is not possible to predict all possible side  effects  or complications associated with receiving vaccine(s). I  understand the risks and benefits associated with the above  vaccine(s)  and  have  received,  read  and/or  had  explained  to  me  the  EUA  Fact  Sheet  on  the  vaccine(s)  I  have elected  to receive. I also acknowledge that I  have  had  a  chance  to  ask  questions  and  that  such  questions  were  answered  to  my  satisfaction. Further, I acknowledge that I have been advised that the  patient  should  remain  near  the  vaccination  location  for  observation for approximately 15 minutes after administration.  On  behalf  of  the  patient,  the  patient’s  heirs  and  personal representatives, I hereby release and hold harmless each applicable Provider, its staff, agents,  successors,  divisions,  affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above."]
["I acknowledge that: (a) I understand the purposes/benefits of my state’s vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, or to any state or federal governmental agencies or  authorities  (“Government Agencies”), such as state, county, or local Departments of Health or the federal Department of Health and Human Services, the Center for Disease Control and Prevention, or their respective  designees  as  may  be  required  by  law, for purposes of public health reporting, or to my healthcare providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s law, I may prevent, by using a state-approved opt-out  form  or,  as  permitted  by  my  state  law,  an  opt-out  form  (“Opt- Out Form”) furnished by the applicable Provider: (a) the disclosure of my vaccination information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and, to the extent required by my state’s law, by signing below, I hereby do consent to the applicable Provider reporting my vaccination information to the Government Agencies, State HIE, or through the State HIE and/or State Registry to the entities and for  the  purposes  described  in  this  Informed  Consent  form. Unless I provide the applicable Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to the applicable Provider and/or my State HIE, as applicable."]
["I understand that even if I do not consent or if I withdraw my consent, my state’s laws or federal law may permit certain disclosures of my vaccination information to or through the State HIE or  to  Government  Agencies  as required or permitted by law. I further authorize     the applicable Provider to: (a) release my medical or  other  information,  including  any  communicable  disease  (including  HIV),  and mental health information, to, or through, the State  HIE  or  Government  Agencies  to  my  healthcare  professionals,  Medicare,  Medicaid, or other third-party payer as necessary to effectuate care or payment; (b) submit a claim to my insurer for the above requested items and services; and (c) request payment  of  authorized  benefits  be  made  on  my behalf  to  the  applicable  Provider  with  respect  to  the  above requested items and services. I further agree to be fully financially responsible for any cost-sharing amounts, including copays, coinsurance and deductibles, for the requested items and services, as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible  is  due  at  the  time  of  service  or,  if  the applicable Provider invoices me after the time of service, upon receipt of such invoice. Walgreens may  disclose  your  vaccination information from this visit for public health purposes  and  will  send  this  information  to  the  Medical  Director  or  Administrator  of  the  LTCF identified above. If you are an employee of the LTCF, Walgreens will send your vaccination information to your employer as required."]
["Print Name: ",null,null,"Patient/Authorized Person signature: ",null,null,null,null,null,"Date: "]
[]
[" SECTION B-1 SCREENING QUESTIONS. The following questions will help us determine your eligibility to be vaccinated today."]
[]
["1.     Do you feel sick today?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["2.     Do you have any health conditions, such as heart disease, diabetes or asthma?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["        'If yes, please list:  _______________________________________________________________________"]
["3.     Do you have allergies to latex, medications, food or vaccines (examples: eggs,         \n         bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or \n         thimerosal)?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
[]
["     'If yes, please list:  _______________________________________________________________________"]
["4.     Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["5.     Have you ever had a seizure disorder for which you are on seizure medication(s), \n       a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or \n       other nervous system problem?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
[]
["6.     For women: Are you pregnant or considering becoming pregnant in the next month?",null,null,null,null,null,null,null,"Yes","No","Don’t know"]
["SECTION B-2 I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient or representative of; or (c) a representative of the LTCF and, based upon clinical observation, have sufficient knowledge of the patient’s condition to answer the Screening Questions. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction."]
[]
["Patient/LTCF Representative",null,null,null,null,null,null,null,"Date:"]
[]
[]
["Please ensure to record BOTH pharmacy AND medical insurance information since there are multiple ways immunizations can be billed at Walgreens."]
[]
["Non-Medicare:",null,"Pharmacy Card",null,"Medical Card",null,null,"Medicare:",null,"Medicare Part B"]
["Insurance Plan/Plan ID:",null,null,null,null,null,null,"Medicare Number:*"]
["Member/Recipient ID #",null,null,null,null,null,null,"*Medicare Claim Number for cards distributed earlier than 2018."]
["RX BIN:",null,null,null,"N/A"]
["RX PCN:",null,null,null,"N/A"]
["Group Number:"]
[]
["Is the patient the cardholder?",null,null,"Yes","No"]
["If no, please provide cardholders name, date of birth (MM/DD/YYY) and relationship: "]
[null,"INSURANCE – PATIENT TO COMPLETE IF APPLICABLE"]
[]
["Complete BEFORE vaccine administration"]
["1.   I have reviewed the Patient Information and Screening Questions.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["2.   I have verified that this is the vaccine requested by the patient.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["3.   This vaccine is appropriate for this patient based on the Age Guidelines and Other Guidelines provided by federal and/or",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["state regulations and company policies."]
["3a. Does this patient have a high-risk medical condition?",null,null,null,null,null,null,null,null,"Yes","No"]
["      If yes, please list medical condition(s):  ________________________________________________________________"]
["4.   The Vaccine NDC matches the NDC on the bottom of this VAR form and the NDC on the patient leaflet. (Perform 3-way NDC match.) ",null,null,null,null,null,null,null,null,"Initial here:","__________"]
["5.   I have verified the Expiration Date is greater than today’s date and have entered the Lot # and Expiration Date in the field below.",null,null,null,null,null,null,null,null,"Initial here:","__________"]
[]
[" SECTION E Complete DURING the patient interaction"]
["1.   I confirm(ed) the patient’s Name, DOB and Requested Vaccine and verified it matches the information on the VAR form.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["2.   I have reviewed the Screening Questions and answers.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
["3.   I provided a EUA Fact Sheet to the patient or the LTCF representative.",null,null,null,null,null,null,null,null,"Initial here: ","__________"]
[]
[" SECTION F "]
["Complete AFTER vaccine administration"]
["Vaccine",null,"NDC",null,"Manufacturer","Dosage","Dose 1","Site of administration",null,"EUA Fact Sheet published date"]
[null,null,null,null,null,null,"Dose 2"]
[]
["Clinician’s name (print): ",null,null,null,null,"Clinician’s signature: ",null,null,"Title:"]
["If applicable, intern/tech name (print): ",null,null,null,null,"Administration date: ",null,null,"Date EUA Fact Sheet given to patient:   "]
[]
["COVID-19 VACCINE LOT# ",null,null,null,null,null,null,"COVID-19 VACCINE EXPIRATION DATE  "]
[]
[]
[]
[]
[]
[]
[]
[]
["1.      Update the patient’s record with any new allergy, health condition or primary care provider information."]
["2.      Enter vaccine lot #, expiration date and side of administartion, then scan the VAR form into the patient's record."]