<p> DFM Policy & Procedure Manual</p><p>Effective Date: Page __1____ Policy # □ Clinical Operations Original X□ __ 3_ Faculty Council 1/1/2011 □ □Revision □ Administrative Title: X□Other Outpatient Immunization Protocol</p><p>PROTOCOL NUMBER: </p><p>PROTOCOL TITLE: Outpatient Immunization Protocol</p><p>PROTOCOL APPLIES TO: UWHC Clinics UWMF Clinics Department of Family Medicine Clinics UWHC Outpatient Pharmacies</p><p>TARGET PATIENT POPULATION: Pediatric & Adult Outpatients</p><p>PROTOCOL CHAMPIONS: James Conway, MD Richard Welnick, MD Sandra Kamnetz, MD Sarah Bland, RPh</p><p>PURPOSE STATEMENT: 1. To establish a process for eligible clinical staff to order and administer indicated immunizations or any of the various available combinations:</p><p> o Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) o Tetanus, diphtheria toxoids and acellular pertussis (for adolescent & adult use) (TdaP) o Tetanus, diphtheria toxoids (Td, Dt) o Measles, mumps and rubella vaccine (MMR) o Poliovirus vaccine inactivated (IPV) o Haemophilus Influenzae Type b (Hib) o Hepatitis A Vaccine o Hepatitis B Vaccine o Pneumococcal Vaccine o Influenza Vaccines o Rotavirus Vaccine o Varicella Vaccine o Meningococcal Vaccine o Human Papillomavirus Vaccine DFM Policy & Procedure Manual</p><p>Effective Date: Page __2____ Policy # □ Clinical Operations Original X□ __ 3___ Faculty Council 1/1/2011 □ □Revision □ Administrative Title: X□Other Outpatient Immunization Protocol</p><p>2. To authorize eligible clinical staff to initiate measures for the emergency management of anaphylactoid reactions to administered immunizations. </p><p>WHO MAY CARRY OUT THIS PROTOCOL: Eligible clinical staff include MA, LPN, RN or authorized Pharmacist (authorized under Wis. Stats. 450.035), as permitted by the policy of the individual organization.</p><p>GUIDELINES FOR IMPLEMENTATION: (Step by step instructions) 1. Interview patient or parent/guardian to assess need and appropriateness for immunization. 2. The order for the indicated immunization will be initiated according to the policy of the individual organization and no co-signature will be required, unless dictated by organizational policy. 3. Document in patient’s medical record: dose, route, injection site, manufacturer, lot number, expiration date, name and title of person administering immunization, date the immunization was administered, Vaccine Information Sheet (VIS) date, and that the immunization was given per Outpatient Immunization Protocol.</p><p>REFERENCES: </p><p>A. American Academy of Pediatrics. 2009 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 1997:32. B. Center for Disease Control and Prevention: Vaccines & Immunizations: http://www.cdc.gov/vaccines C. Immunization Action Coalition (IAC): Vaccine Information for Health Care Professionals: http://www.immunize.org D. State of Wisconsin Department of Regulation and Licensing: Pharmacy Examining Board: http://drl.wi.gov/boards/phm/ DFM Policy & Procedure Manual</p><p>Effective Date: Page __3____ Policy # □ Clinical Operations Original X□ __ 3__ Faculty Council 1/1/2011 □ □Revision □ Administrative Title: X□Other Outpatient Immunization Protocol</p><p>RESPONSIBLE DEPARTMENT: Department of Internal Medicine Department of Pediatrics Department of Family Medicine Department of Pharmacy</p><p>APPROVING COMMITTEE: UWHC Ambulatory Protocol Committee UWHC P&T Committee Immunization Task Force</p><p>Authorization: Date: 12/20/2010</p>