An advanced pharmacy technician who engages in the administration of vaccines shall, for a minimum of 4 years, keep a patient consent form that includes the:

1. (a) Name and date of birth of the patient;
2. (b) Name of the vaccine, manufacturer, lot number, and expiration date of the vaccine;
3. (c) Description of the risks and possible side effects of the vaccine;
4. (d) Date of administration;
5. (e) Supervising pharmacist’s name;
6. (f) Administering licensed pharmacy technician’s name; and
7. (g) Signature of the patient.

Source. #13463, eff 10-18-22