FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

CVX Codes See also: http://www2a.cdc.gov/vaccines/IIS/IISStandards/vaccines.asp?rpt=cvx

Code 1* 2* 3 4 5 6 7 8 9 10 14 15 17* 18 20 21 22* 25 26 28 30 31 32 33 34 35 37 38* 39 41 42 43 44 45 47* 48 49 50 51 52 53 62 66 83 84

Description DTP OPV MMR M/R Measles Rubella Mumps Hep B, adolescent or pediatric Td (adult) IPV Immune globulin, NOS Influenza, split(pur surf ant) Hib, NOS Rabies, intramuscular inj DTaP Varicella DTP-Hib Typhoid, oral CHOLERA DT (PEDIATRIC) HBIG Hep A, pediatric, NOS Meningococcal polysaccharide vaccine (MPSV4) Pneumoccocal polysaccharide vaccine (PPSV23) RIG Tetanus toxoid Yellow fever Rubella/Mumps Japanese encephalitis Typhoid, parenteral, non-AKD Hep B, adol/high risk infant Hep B, adult Hep B, dialysis Hep B, NOS Hib (HbOC) Hib (PRP-T) Hib (PRP-OMP) DTaP-Hib Hib-Hep B Hep A, adult Typhoid, parenteral, AKD (US MIL) Human Papilloma Virus vaccine (quadrivalent) Lyme disease Hep A, ped/adol, 2 dose Hep A, ped/adol, 3 dose

1

FLSHOTS Vacc. Type DTP OPV MMR MR MEASLES RUBELLA MUMPS HEP B TD IPV GAMMA FLU3Y+ P HIB (UNK) RABIES IM DTAP VZV DTP-ACTHIB TYPHOID PO CHOLERA DT HBIG HEP A MPSV4 PPSV23 RIG TD YELLOW FEV MUMPS-RUB JENCEPH TYPHOID IM HEP B HEP B2DOSE HEP B HEP B HIB (HBOC) HIB PRP-T HIB PRPOMP DTAP-HIB HIB-HEPB HEP A TYPHOID IM HPV4 LYME HEP A HEP A

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

85 88* 89 90 91 94 100* 101 104 106 107 108 109 110 111 112 113 114 115 116 118 119 120 121 125 126 127 128 130 133 135 136 138 140** 141** 144 147 148 149 150** 153 155 158** 161 162 163 165 166

Hep A, NOS Influenza, NOS Polio, NOS Rabies, NOS Typhoid, NOS MMRV Pneumococcal conjugate vaccine (PCV7) Typhoid, ViCPs Hep A-Hep B DTaP, 5 pertussis antigens DtaP, NOS Meningococcal, NOS Pneumococcal, NOS DtaP-HeP B-IPV Influenza, live, intranasal Tetanus toxoid, NOS Td, adsorbed, preservative free Meningococcal conjugate vaccine (MCV4P, Menactra) Tdap Rotavirus vaccine, pentavalent, 3-dose, live, oral Human Papilloma Virus vaccine (bivalent) Rotavirus vaccine, monovalent, 2-dose, live, oral Pentacel (Dtap-ActHib-IPV) Zoster VZV (Shingles) vaccine, live Novel Influenza-H1N1-09, Nasal Novel Influenza-H1N1-09, Preservative-free Novel Influenza-H1N1-09 Novel Influenza-H1N1-09, All Formulations Kinrix (Dtap-IPV) Pneumococcal conjugate vaccine (PCV13) Influenza, high-dose seasonal Meningococcal conjugate vaccine (MCV4O, Menveo) TD (adult) – Non-adsorbed Influenza, seasonal, injectable, preservative free Influenza, seasonal, injectable Influenza, seasonal, intradermal, preservative free Meningococcal, MCV4, unspecified formulation Meningococcal conjugate vaccine + Hib (Hib-MenCY) Influenza, live, intranasal, quadrivalent Influenza, injectable, quadrivalent, preservative free Influenza, injectable, MDCK, preservative free Influenza, recombinant, injectable, preservative free Influenza, injectable, quadrivalent, Influenza, injectable, quadrivalent, 6-35m, PF Meningococcal B, recombinant Meningococcal B, OMV Human Papilloma Virus vaccine (HPV9) Influenza, intradermal, quadrivalent, preservative free

2

HEP A FLU UNK IPV RABIES IM TYPHOID IM MMRV PCV7 TYPHOID IM HEPA-HEPB DTAP DTAP MENOMUNE PNEU PEDIARIX FLU-MIST TD TD TENIVAC MCV4 TDAP ROTATEQ HPV2 ROTARIX PENTACEL ZOSTER VZV H1N109 MST H1N109 PF H1N109 P H1N109 UNK DTAP-IPV PCV13 FLU HIDOSE MCV4 TD FLU3Y+ PF FLU3Y+ P FLU-ID MCV4 MENHIBRIX FLU-MIST FLU3Y+ PF FLUCELVAX FLUBLOK FLU3Y+ P FLU6-35 PF TRUMENBA BEXSERO HPV9 FLU-ID

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

CPT Codes See also: http://www2a.cdc.gov/vaccines/IIS/IISStandards/vaccines.asp?rpt=cpt

Code 90371 90375 90376 90470 90620 90621 90630 90632 90633 90634 90636 90644 90645* 90647 90648 90649 90650 90651 90654 90655 90656 90657 90658 90660 90661 90662 90663 90664 90665 90666 90668 90669* 90670 90672 90673 90675 90680 90681 90685 90686 90687

Description Hepatitis B immune globulin Rabies immune globulin Rabies immune globulin, heat-treated Novel Influenza-H1N1-09, All Formulations Meningococcal B, OMV Meningococcal B, recombinant Influenza, intradermal, quadrivalent, preservative free Hepatitis A vaccine, adult dosage Hep A vaccine ped./adol. Dosage, 2 dose schedule Hepatitis A, ped/adol dose (3-dose) Hepatitis A and Hepatitis B vaccine Meningococcal conjugate vaccine + Hib (Hib-MenCY) Haemophilus influenza type b vaccine, HbOC conjuga Haemophilus influenza type b vaccine, PRP-OMP conj Haemophilus influenza type b vaccine, PRP-T conjug Human Papilloma Virus vaccine (quadrivalent) Human Papilloma Virus vaccine (bivalent) Human Papilloma Virus vaccine (HPV9) Influenza, seasonal, intradermal, preservative free Influenza, split virus, preservative free, 6-35 months Influenza, split virus, preservative free, 3Y+ Influenza, split virus, 6-35 months Influenza, split virus, 3Y+ Influenza, live, intranasal Influenza, injectable, MDCK, preservative free Influenza, high-dose seasonal Novel Influenza-H1N1-09, All Formulations Novel Influenza-H1N1-09, nasal Lyme disease vaccine Novel Influenza-H1N1-09, preservative free Novel Influenza-H1N1-09 Pneumococcal conjugate vaccine (PCV7) Pneumococcal conjugate vaccine (PCV13) Influenza, live, intranasal, quadrivalent Influenza, recombinant, injectable, preservative free Rabies, intramuscular inj Rotavirus vaccine, pentavalent, 3-dose, live, oral Rotavirus vaccine, monovalent, 2-dose, live, oral Influenza, quadrivalent, preservative free, 6-35 months Influenza, quadrivalent, preservative free, 3Y+ Influenza, quadrivalent, 6-35 months

3

FLSHOTS Vacc. Type HBIG RIG RIG-HT H1N109 UNK BEXSERO TRUMENBA FLU-ID HEP A HEP A HEP A HEPA-HEPB MENHIBRIX HIB (HBOC) HIB PRPOMP HIB PRP-T HPV4 HPV2 HPV9 FLU-ID FLU6-35 PF FLU3Y+ PF FLU6-35 P FLU3Y+ P FLU-MIST FLUCELVAX FLU HIDOSE H1N109 UNK H1N109 MST LYME H1N109 PF H1N109 P PCV7 PCV13 FLU-MIST FLUBLOK RABIES IM ROTATEQ ROTARIX FLU6-35 PF FLU3Y+ PF FLU6-35 P

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

90688 90690 90691 90692 90693 90696 90698 90700 90701* 90702 90703 90704 90705 90706 90707 90708 90709* 90710 90712* 90713 90714 90715 90716 90717 90718 90720* 90721 90723 90724* 90725 90726 90731 90732 90733 90734 90735 90736 90737* 90740 90741 90743 90744 90745 90746 90747 90748

Influenza, quadrivalent, 3Y+ Typhoid vaccine, live, oral Typhoid, ViCPs Typhoid (HP) Typhoid vaccine (AKD) Kinrix (Dtap-IPV) Pentacel (Dtap-ActHib-IPV) Diphtheria, tetanus toxoids and acellular pertussis Diphtheria, tetanus toxoids and pertussis vaccine Diphtheria and tetanus toxoids, adsorbed for pedia Tetanus toxoid Mumps virus vaccine Measles virus vaccine Rubella virus vaccine Measles, Mumps and Rubella virus vaccine Measles and Rubella virus vaccine Rubella and Mumps virus vaccine Measles, Mumps, Rubella and Varicella virus vaccin Poliovirus vaccine, live, oral Poliovirus vaccine, inactivated Td, adsorbed, preservative free Tetanus toxoid, reduced diphtheria toxoid and acce Varicella virus vaccine Yellow fever vaccine Tetanus and diphtheria toxoids, adsorbed for adult DTP-Haemophilus influenza type b conjugate vaccine DTaP-Haemophilus influenza type b conjugate vaccin DTap- hepatitis B and poliovirus vaccine Influenza virus vaccine, NOS Cholera vaccine Rabies vaccine Hepatitis B vaccine Pneumococcal polysaccharide vaccine Meningococcal polysaccharide vaccine (MPSV4) Meningococcal conjugate vaccine (MCV4) Japanese encephalitis vaccine Zoster VZV (Shingles) vaccine, live Haemophilus influenza type b vaccine, conjugate NOS Hepatitis b, dialysis or immun suppressed (3 dose) Immune globulin, NOS Hepatitis B vaccine, adult dosage Hepatitis B vaccine, ped. or ped./adol. dosage Hepatitis b, adol/high risk infant Hepatitis b, adult dosage Hepatitis b, dialysis or immun suppressed (4 dose) Haemophilus influenza type b conj. and Hep B vacci

FLU3Y+ P TYPHOID PO TYPHOID IM TYPHOID IM TYPHOID IM DTAP-IPV PENTACEL DTAP DTP DT TD MUMPS MEASLES RUBELLA MMR MR MUMPS-RUB MMRV OPV IPV TD TENIVAC TDAP VZV YELLOW FEV TD DTP-ACTHIB DTAP-HIB PEDIARIX FLU UNK CHOLERA RABIES IM HEP B PPSV23 MPSV4 MCV4 JENCEPH ZOSTER VZV HIB (UNK) HEP B GAMMA HEP B2DOSE HEP B HEP B HEP B HEP B HIB-HEPB

* Vaccination records sent with these codes will be rejected if indicated as administered after a certain date and if indicated that the vaccination was provided by the sending organization (code 4

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

00, submitted in delimited field 34 or RXA-9 in an HL7 file/message). If not indicated as provided by the sending organization, the record will be considered historical. See table below.

FLSHOTS Vaccine Type DTP DTP-ACTHIB FLU UNK HIB (HBOC) HIB (UNK) MUMPS-RUB OPV PCV7

End Date 01/01/2001 01/01/2001 01/01/1999 12/31/2007 01/01/1999 12/31/2001 01/01/2001 11/30/2013

Notes regarding flu vaccines: When using CVX codes, codes for use in documenting historical non-quadrivalent seasonal influenza vaccine (not mist, high-dose, or intradermal) are CVX 140 and CVX 141 (CVX 15 was discontinued in favor of CVX 140 and CVX 141). Similar codes for quadrivalent seasonal influenza are CVX 150 and 158. ** Note that there are two possible FLSHOTS vaccine types which each of these seasonal influenza CVX codes can match to according to age group. As a result, CVX 140/150 is matched to “FLU3Y+ PF” and CVX 141/158 is matched to “FLU3Y+ P” as long as the patient’s age is 3 years or older. If the patient is younger than three years and CVX 140/150 or CVX 141/158 is sent, the vaccine type will be “FLU6-35 PF” and “FLU6-35 P”, respectively. CVX 161 breaks with this pattern by being specific to 6-35 PF. CPT 90724 and CVX 88 are for unknown or non-specific Influenza virus vaccine and theses codes have been inactivated by their respective issuing agencies as of 1/1/99. In the interest of capturing flu vaccinations, FLSHOTS will associate CVX 88 and CPT 90724 with the FLSHOTS vaccine type of “FLU UNK”. Please verify all vaccinations for accuracy within Florida SHOTS and make any needed changes manually.

Other Vaccination Codes Code G9141 G9142 Q2035 Q2036 Q2037 Q2038 Q2039

Description Novel Influenza-H1N1-09, All Formulations Novel Influenza-H1N1-09, All Formulations Afluria vacc, 3 yrs & >, im Flulaval vacc, 3 yrs & >, im Fluvirin vacc, 3 yrs & >, im Fluzone vacc, 3 yrs & >, im NOS flu vacc, 3 yrs & >, im

5

FLSHOTS Vacc. Type H1N109 UNK H1N109 UNK FLU3Y+ P FLU3Y+ P FLU3Y+ P FLU3Y+ P FLU3Y+ P

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

Manufacturer Codes See also: http://www2a.cdc.gov/vaccines/IIS/IISStandards/vaccines.asp?rpt=mvx

MVX Code AB AD AKR ALP BRR BAH BPC BTP CRU CSL DVC MIP GEO SKB GRE GRF IDB IUS INT JNJ KED KGC MBL MED MSD NAB NYB NOV NVX OTC ORT OTH PFR PSC PMC SCL TAL JPN

USA

Manufacturer Name Abbott Laboratories Adams Laboratories, Inc. Akorn, Inc Alpha Therapeutic Corporation Barr Laboratories Baxter Healthcare Corporation Berna Products Corporation Biotest Pharmaceuticals Corporation Crucell CSL Behring, Inc DynPort Vaccine Company, LLC Emergent BioDefense Operations Lansing GeoVax Labs, Inc. GlaxoSmithKline Greer Laboratories, Inc. Grifols ID Biomedical Immuno-U.S., Inc. Intercell Biomedical Johnson and Johnson Kedrian Biopharma Korea Green Cross Corporation Massachusetts Biologic Laboratories MedImmune, Inc. Merck and Co., Inc. NABI New York Blood Center Novartis Pharmaceutical Corporation Novavax, Inc. Organon Teknika Corporation Ortho-clinical Diagnostics Other manufacturer Pfizer, Inc Protein Sciences sanofi pasteur Sclavo, Inc. Talecris Biotherapeutics The Research Foundation for Microbial Diseases of Osaka University (BIKEN) United States Army Medical Research and Material Command

6

CDC Status Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active Active

Active

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

UNK WAL ACA AR AVB AVI BA BAY BP CNJ CMP CEN CHI CON EVN IAG LED MA IM MIL NAV PD PWJ PRX SOL SI VXG WA ZLB

Unknown manufacturer Wyeth Acambis, Inc Armour Aventis Behring L.L.C. Aviron Baxter Healthcare Corporation-inactive Bayer Corporation Berna Products Cangene Corporation Celltech Medeva Pharmaceuticals Centeon L.L.C. Chiron Corporation Connaught Evans Medical Limited Immuno International AG Lederle Massachusetts Public Health Biologic Laboratories Merieux Miles North American Vaccine, Inc. Parkedale Pharmaceuticals PowderJect Pharmaceuticals Praxis Biologics Solvay Pharmaceuticals Swiss Serum and Vaccine Inst. VaxGen Wyeth-Ayerst ZLB Behring

Active Active Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive Inactive

Injection Routes See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=1E042B59-15B8-DF11-9BDD-0015173D1785

FLSHOTS Code SC IM NS PO ID OTH

FDA Code (NCIT) C38299 C28161 C38284 C38288 C38238

Description SUBCUTANEOUS INTRAMUSCULAR NASAL ORAL INTRADERMAL OTHER

7

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

Injection Sites See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=98257779-17B8-DF11-9BDD-0015173D1785

Code LT LVL LA LD LG RT RVL RA RD RG

Description Left Thigh Left Vastus Lateralis Left Arm Left Deltoid Left Gluteous Medius Right Thigh Right Vastus Lateralis Right Arm Right Deltoid Right Gluteous Medius

Historical Identifier (Immunization Information Source) See also: https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.114222.4.5.293# Note: These are codes used to describe the source of each immunization record which will determine if the vaccination was historical or provided by the clinic sending the data. ‘00’, a null value, or any value not in the below table will indicate to FLSHOTS that the vaccination was new, while ‘01’ through ‘08’ will indicate the vaccination was historical.

Value 00 01 02 03 04 05 06 07 08

Description New immunization record Historical information - source unspecified Historical information - from other provider Historical information - from parent's written record Historical information - from parent's recall Historical information - from other registry Historical information - from birth certificate Historical information - from school record Historical information - from public agency

VFC Eligibility (Financial Class) See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=1553768E-88BA-DF11-9BDD-0015173D1785

Code V01

V02

V03 V04

Label Not VFC eligible

VFC eligibleMedicaid/Medicaid Managed Care VFC eligible- Uninsured VFC eligible- American Indian/Alaskan Native

Definition Client does not qualify for VFC because they do not have one of the statuses below. This category does not include the underinsured (see V08). Client is currently on Medicaid or Medicaid managed care. Client does not have insurance coverage for vaccinations. Client is a member of a federally recognized tribe.

8

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

V05

VFC eligible-Federally Qualified Health Center Patient (under-insured)

Client has insurance that partially covers vaccines received on visit and so is eligible for VFC coverage at a Federally Qualified Health Center. The client must be receiving the immunizations at the FQHC.

Immunization Funding Source See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=2DD050CD-9AB9-DF11-9BDD-0015173D1785 Note: Used to convey source of funding for vaccine being administered to help in correctly identifying VFC vaccinations. When used in HL7-formatted messages (see “Observation Identifier” in the HL7 Use Only section below), values are placed in OBX-5 as an answer to the question posed in OBX-3 when OBX-3.1 = 30963-3. Code values may also be used as shown in delimited format submissions (only the code, not the name).

Code (OBX-5.1) PHC70 VXC1 VXC2 PHC68 VXC3 OTH UNK

Name (OBX-5.2) Private funds Federal funds State funds Military funds Tribal funds Other Unspecified

Race See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=67D34BBC-617F-DD11-B38D-00188B398520 US and NIP race codes are shown in the table below. The “FLSHOTS Race” column indicates what the race will convert to in Florida SHOTS. Note: The US race code values are consistent with the OMB Notice of revised categories for collection of race and ethnicity data—the combined format. The NIP original race codes are still allowed for backwards compatibility and are included below for reference. NIP codes do not distinguish between Asian or Pacific Islander; ‘A’ is used for both.

US race codes 1002-5

NIP Original Race Codes I

2028-9 2076-8

A A

2054-5

B

2106-3 2131-1

W O



U

Description American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or AfricanAmerican White Other Race

FLSHOTS Race

AMERICAN INDIAN/ALASKAN OTHER ASIAN OTHER PACIFIC ISLANDER BLACK/AFRICAN AMERICAN WHITE OTHER NONWHITE Unknown/undetermined UNKNOWN

9

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

Contraindication Codes Code ALL1 ALL2 ALL3 ALL4

DTP1

DTP2

DTP3 DTP4

DTP5 DTP6 DTP8 H1N11 H1N12

H1N13 H1N14 HEP1 HEP6 HEP8 HEPA1 HEPA2 HEPA3 HEPA6

Description ANAPHYLACTIC REACTION TO A VACCINE ANAPHYLACTIC REACTION TO A VACCINE CONSTITUENT MODERATE OR SEVERE ILLNESSES WITH OR WITHOUT A FEVER OTHER TEMPORARY CONTRAINDCATION ENCEPHALOPATHY WITHIN 7 DAYS OF ADMINISTRATION OF PREVIOUS DOSE OF DTP FEVER OF >=40.5 DEGREES C (105 DEGREES F) WITHIN 48 HOURS AFTER VACCINATION WITH A PRIOR DOSE OF DTP COLLAPSE OR SHOCKLIKE STATE (HYPOTONIC-HYPORESPONSIVE EPISODE) WITHIN 48 HOURS OF RECEIVING A PRIOR DOSE OF DTP SEIZURES WITHIN 3 DAYS OF RECEIVING A PRIOR DOSE OF DTP PERSISTENT, INCONSOLABLE CRYING LASTING >=3 HOURS WITHIN 48 HOURS OF RECEIVING A PRIOR DOSE OF DTP ANAPHYLACTIC REACTION TO A VACCINE OTHER TEMP (DTAP) ANAPHYLACTIC REACTION TO EGG INGESTION AND TO NEOMYCIN ANAPHYLACTIC REACTION TO A VACCINE CONCOMITANT PEDIATRIC AND ADOLESCENT ASPIRIN THERAPY AND REYE’S SYNDROME OTHER TEMP (H1N109) ANAPHYLACTIC REACTION TO COMMON BAKER'S YEAST LAB CONFIRMED IMMUNITY OTHER TEMP (HEPB) ANAPHYLACTIC REACTION TO VACCINE OR COMPONENTS MODERATE OR SEVERE ILLNESSES WITH OR WITHOUT A FEVER OTHER TEMP (HEP A) LAB CONFIRMED IMMUNITY

10

Perm/ Temp

Valid Type(s)

Valid Series

PERM

ALL

PERM

ALL

TEMP

ALL

TEMP

ALL

PERM

DTAP

PERM

DTAP

PERM

DTAP

PERM

DTAP

PERM

DTAP

PERM TEMP

DTAP DTAP

PERM

H1N109

PERM

H1N109

H1N109 PERM MST TEMP

H1N109

PERM PERM TEMP

HEP B HEP B HEP B

PERM

HEP A

TEMP TEMP PERM

HEP A HEP A HEP A

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

ANAPHYLACTIC REACTION TO A VACCINE OTHER TEMP (HIB) ANAPHYLACTIC REACTION TO VACCINE HMCY1 OR VACCINE COMPONENTS HMCY2 OTHER TEMP (HIBMENCY) ANAPHYLACTIC REACTION TO A HPV1 VACCINE HPV2 OTHER TEMP (HPV) HIB1 HIB8

IPV1

ANAPHYLACTIC REACTION TO NEOMYCIN OR STREPTOMYCIN

IPV2

PREGNANCY

IPV8

OTHER TEMP (IPV) ANAPHYLACTIC REACTION TO EGG INGESTION AND TO NEOMYCIN KNOWN ALTERED IMMUNODEFICIENCY (HEMATOLOGIC AND SOLID TUMORS; CONGENITAL IMMUNODEFICIENCY; AND LONG-TERM IMMUNOSUPPRESSIVE THERAPY) PREGNANCY RECENT IMMUNE GLOBULIN ADMINISTRATION TB - UNTREATED, ACTIVE LAB CONFIRMED IMMUNITY OTHER TEMP (MEASLES) ANAPHYLACTIC REACTION TO VACCINE OR VACCINE COMPONENTS OTHER TEMP (MEN) ANAPHYLACTIC REACTION TO VACCINE OR VACCINE COMPONENTS ANAPHYLACTIC REACTION TO EGG INGESTION AND TO NEOMYCIN KNOWN ALTERED IMMUNODEFICIENCY (HEMATOLOGIC AND SOLID TUMORS; CONGENITAL IMMUNODEFICIENCY; AND LONG-TERM IMMUNOSUPPRESSIVE THERAPY) PREGNANCY RECENT IMMUNE GLOBULIN ADMINISTRATION TB - UNTREATED, ACTIVE

MEA1

MEA2 MEA3 MEA4 MEA5 MEA6 MEA8 MEN1 MEN4 MENB1 MUM1

MUM2 MUM3 MUM4 MUM5

11

PERM TEMP

HIB HIB

PERM TEMP

HIBMENCY HIBMENCY

PERM TEMP

HPV HPV

IPV, PEDIARIX, PENTACEL, PERM DTAP-IPV IPV, PEDIARIX, PENTACEL, TEMP DTAP-IPV IPV, PEDIARIX, PENTACEL, TEMP DTAP-IPV PERM

MEASLES

PERM TEMP

MEASLES MEASLES

TEMP PERM PERM TEMP

MEASLES MEASLES MEASLES MEASLES

PERM TEMP

MEN MEN

PERM

MENB

PERM

MUMPS

PERM TEMP

MUMPS MUMPS

TEMP PERM

MUMPS MUMPS

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

MUM6 MUM8 OPV1

OPV2 OPV3 OPV4 OPV8 PNC1 PNC8 POL1

POL2 POL3 POL4 POL7 POL8 ROT1 ROT2 ROT3 RUB1

RUB2 RUB3 RUB4 RUB5 RUB6 RUB8 SPX1 SPX10 SPX2

LAB CONFIRMED IMMUNITY OTHER TEMP (MUMPS) INFECTION WITH HIV OR A HOUSEHOLD CONTACT WITH HIV KNOWN ALTERED IMMUNODEFICIENCY (HEMATOLOGIC AND SOLID TUMORS; CONGENITAL IMMUNODEFICIENCY; AND LONG-TERM IMMUNOSUPPRESSIVE THERAPY) IMMUNODEFICIENT HOUSEHOLD CONTACT PREGNANCY OTHER TEMP (OPV) ANAPHLACTIC REACTION TO VACCINE OTHER TEMP (PNEU) INFECTION WITH HIV OR A HOUSEHOLD CONTACT WITH HIV KNOWN ALTERED IMMUNODEFICIENCY (HEMATOLOGIC AND SOLID TUMORS; CONGENITAL IMMUNODEFICIENCY; AND LONG-TERM IMMUNOSUPPRESSIVE THERAPY IMMUNODEFICIENT HOUSEHOLD CONTACT ANAPHYLACTIC REACTION TO NEOMYCIN OR STREPTOMYCIN PREGNANCY OTHER TEMP (POL) MODERATE OR SEVERE ACUTE ILLNESS ANAPHYLACTIC REACTION TO A VACCINE SEVERE COMBINED IMMUNODEFICIENCY ANAPHYLACTIC REACTION TO EGG INGESTION AND TO NEOMYCIN KNOWN ALTERED IMMUNODEFICIENCY (HEMATOLOGIC AND SOLID TUMORS; CONGENITAL IMMUNODEFICIENCY; AND LONG-TERM IMMUNOSUPPRESSIVE THERAPY) PREGNANCY RECENT IMMUNE GLOBULIN ADMINISTRATION TB - UNTREATED, ACTIVE LAB CONFIRMED IMMUNITY OTHER TEMP (RUBELLA) PREGNANCY BREASTFEEDING ECZEMA/ATOPIC DERMATITIS

12

PERM TEMP

MUMPS MUMPS

PERM OPV

PERM OPV PERM OPV TEMP OPV TEMP OPV PERM TEMP

PNEUCON PNEUCON

PERM

POLIO

PERM

POLIO

PERM

POLIO

PERM TEMP TEMP TEMP

POLIO POLIO POLIO ROTAVIRUS

PERM

ROTAVIRUS

PERM

ROTAVIRUS

PERM

RUBELLA

PERM TEMP

RUBELLA RUBELLA

TEMP PERM PERM TEMP TEMP TEMP PERM

RUBELLA RUBELLA RUBELLA RUBELLA SMPOX SMPOX SMPOX

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

SPX3 SPX4 SPX5 SPX6 SPX7 SPX8 SPX9 VZV1 VZV2 VZV3 VZV4 VZV5 VZV6 VZV8

IMMUNODEFICIENCY ANAPH REAC TO VACCINE MODERATE/SEVERE ACUTE ILLNESS IMMUNODEFICIENT HOUSEHOLD CONTACT HEART DISEASE OR OTHER HEART CONDITION HAD A STROKE OR TRANSIENT ISCHEMIC ATTACK THREE OR MORE RISK FACTORS VZV1 - Not Susceptible/Had Disease ANAPHYLACTIC REACTION TO VACCINE IMMUNODEFICIENCY TB - UNTREATED, ACTIVE PREGNANCY LAB CONFIRMED IMMUNITY OTHER TEMP (VZV)

PERM PERM TEMP

SMPOX SMPOX SMPOX

PERM

SMPOX

PERM

SMPOX

PERM PERM PERM PERM PERM PERM TEMP PERM TEMP

SMPOX SMPOX VZV VZV VZV VZV VZV VZV VZV

HL7 Use Only: See FLSHOTS file specifications for HL7 messaging at http://www.flshots.com/_pdfs/HL7_FLSHOTS.pdf

Identifier Type See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=774F6448-F21E-49EF-A9AC-AA60DEAA061D Note: Used in HL7 segment PID-3 to describe the type of identifier(s) used. Multiple identifiers are allowed in PID3, separated by the repetition character ‘~’ in the format of number^^^^type~number^^^^type. For Florida SHOTS, a unique identifier associated with the patient is required (type ‘MR’). Other identifiers are optional. Only the identifier types listed below are used by Florida SHOTS at this time.

Value MR MA SS

Description Medical record number/chart number/patient id from sending system Medicaid ID number Social Security Number

Observation Identifier See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=C0453761-23B8-4257-B3F3-C25CA089820D Note: Used in OBX-3 to setup a question, answered in OBX-5. LOINC stands for Logical Observation Identifiers Names and Codes. Many other codes exist but only the listed values below are used by Florida SHOTS at this time.

LOINC Code (OBX 3.1)

Description (OBX 3.2)

30956-7

Vaccine type (CVX)

38890-0 30963-3

Component vaccine type (CVX) Vaccine funding source Date Vaccine Information Statement Published

29768-9

13

FLORIDA SHOTS VALID VALUES Last Updated 4/27/15

64994-7

Vaccine funding program eligibility category (Vxx)

Relationship to Patient See also: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=CA8EDFF4-F037-49A7-82B5-08B9380BEB6A Note: Used in NK1-3 to identify how the indicated next-of-kin is related to the patient. Other types are possible but only MTH and FTH are used by Florida SHOTS at this time.

Value MTH FTH

Description Mother Father

14