Immunization Orientation and Competency Verification Procedure for Non-VDH Employee Vaccinators
The purpose of this document is to outline the procedure for Medical Reserve Corps (MRC) volunteers and other healthcare professionals who provide vaccinations under the auspices of the Virginia Department of Health (VDH).
Proper vaccine administration is vital for preventing many common, vaccine-preventable diseases. Vaccine administration errors may result in the need to revaccinate patients, missed opportunities to prevent communicable diseases, and the potential for significant financial loss due to wasted vaccines. Furthermore, since public health entities are considered “gold standards” of vaccination knowledge and techniques, inappropriate vaccine administration can result in damage to the public’s confidence in vaccine effectiveness and the reputation of the health department.
This procedure is applicable to all non-VDH employee vaccinators, including MRC volunteers (RNs, NPs, LPNs, pharmacists, physician assistants, and physicians), nursing students, and Emergency Medical System (EMS) staff. All individuals who function in the capacity of vaccinators for VDH serve under the supervision of fully trained public health nurses who have completed the VDH immunization training or a contract/volunteer immunization nurse who has completed training and has been trained by the district nurse manager, Immunization Action Plan (IAP) Coordinator or their designee. Vaccinators who receive vaccines purchased by the Office of Emergency Preparedness for closed Points of Dispensing (POD) operations that are not supervised by a fully trained VDH public health nurse or contractor/volunteer designee, will be responsible for cold chain management of the vaccine, responding to emergency events at the POD, and entering data into the Virginia Immunization Information System (VIIS).
Although the Public Readiness and Emergency Preparedness (PREP) Act is currently in effect that allows certain individuals previously trained to administer COVID-19 and Mpox vaccines, the VDH is advising health districts to only use currently licensed individuals to administer vaccines.
Medical Reserve Corps Volunteer Vaccinators
The MRC Coordinator or their designee is responsible for making sure that each MRC volunteer has a current and unencumbered MD, PA, NP, RN, LPN, or Pharmacist license in Virginia.
Nurses with out-of-state licenses may practice with a current and unencumbered license issued from an Enhanced Nursing licensure compact (eNLC) state. States that are members of the eNLC allow nurses in member states to practice physically, electronically and/or telephonically across a state border in other states that are members of the eNLC. LPNs may provide immunizations under the supervision of an RN.
The MRC Coordinator or designee must ensure that prior to the start of any work within VDH, all MRC volunteers have:
- A volunteer orientation,
- Passed background investigation,
- A current CPR certification, and
- A current, unencumbered healthcare professional license.
Emergency Medical Services (EMS) Vaccinators
In order for EMS providers to support VDH vaccination clinics, according to §54.1-3408 of the Code of Virginia, they must:
- Hold a valid, unrestricted Virginia certification as an Intermediate or Paramedic,
- Be affiliated with the Virginia EMS agency developing the vaccination program,
- Be individually approved by their agency Operational Medical Director (OMD) as a vaccinator, and
- Follow protocols approved by their OMD for vaccine administration.
The Virginia EMS Agency, where the EMS provider is affiliated, shall provide confirmation to VDH that the provider meets the requirements above. Virginia EMS providers supporting VDH vaccination clinics must complete the VDH Procedures for Evaluating Immunization Knowledge and Skills Assessment Checklist for Vaccinators listed below; these procedures are encouraged to be used for their vaccination program and closed POD vaccination efforts.
MRC volunteers that are EMS providers can ONLY provide vaccinations under the direction of their EMS Agency and OMD as outlined above. MRC coordinators will NOT be responsible for managing EMS providers as MRC volunteers.
Nursing Students as Vaccinators
“Nurses comprise the largest healthcare workforce, and opportunities exist to strengthen disaster readiness, enhance national sure capacity, and build community resiliency to disasters.” (Veenema et al., 2016). For this reason, VDH hosts schools of nursing for community health rotations, including nursing students in immunization events to provide an introduction to emergency preparedness, the role of immunization in disease prevention, and epidemiology. Per 18VAC90-27-110, “In accordance with §54.1-3001 of the Code of Virginia, a nursing student, while enrolled in an approved nursing program, may perform tasks that would constitute the practice of nursing.”
There are additional requirements for nursing students and their faculty or preceptors, which are outlined in 18VAC90-27-110 and/or in the VDH Memorandum of Agreement (MOA) that are required of all schools of nursing. Provision of adult immunizations may be included in the MOA; all MOAs preclude the immunization of children.
VDH nurses, including volunteers, may serve as preceptors as long as they are licensed at or above the level for which the student is preparing. Some degree programs or schools, however, require the preceptor to be licensed and educationally prepared at or above the level for which the student is preparing.
Nursing students are welcome to join a MRC unit, but they are ONLY able to vaccinate when affiliated and supervised by their nursing program. Nursing students must perform the skill in the simulation lab and be checked off by their instructor or preceptor prior to vaccinating under their instructor or preceptor.
In addition to administering a vaccine to a person of any age pursuant to a valid prescription, which directs the pharmacist to administer the vaccine as part of the dispensing process, there are regulations which address pharmacist initiation and administration of immunizations.
- Section I of 54.1-3408 of the Drug Control Act authorizes a pharmacist to administer immunizations to adults under a Board of Nursing-approved protocol, and Section W authorizes a pharmacist to administer an influenza vaccine to minors under guidelines developed by the Virginia Department of Health.
- The Virginia Board of Pharmacy’s (BOP) statewide protocol for a pharmacist to initiate treatment with a vaccine on the CDC’s Immunization Schedule, or to direct a pharmacy technician or pharmacy intern to administer the vaccine under the supervision of the pharmacist to persons 18 years of age or older will also expire at the end of the day on May 11, 2023.
- However, a revised statewide protocol, effective 5/12/23, for pharmacists to initiate vaccination with a vaccine on the CDC’s Immunization Schedule, including COVID-19 and influenza, or to direct a pharmacy technicians or pharmacy intern to administer the vaccine under the supervision of the pharmacist to persons 3 years of age or older.
- ￼￼, 2020).Virginia Board of Pharmacy, 2020).
HHS Secretary Becerra’s April 14th announcement, the declaration under the PREP Act for medical countermeasures against COVID-19 will extend through December 2024 to pharmacists, pharmacy interns, and pharmacy technicians to administer COVID-19 and influenza vaccines to individuals 3 years of age and over.
- However, the PREP Act will no longer allow pharmacists to initiate and administer other childhood vaccines to those 3 years and older.
In summary of the above regulations, a pharmacist may order and administer COVID-19 and influenza vaccines to individuals ages 3 years and older, pursuant to the PREP Act declaration and/or Virginia statewide protocols. A pharmacist may order and administer other ACIP-recommended childhood vaccines to individuals ages 3 years and older, pursuant to statewide protocols.
Pharmacists who serve as MRC volunteer vaccinators must complete the required training and skills assessment checklist as outlined in the training plan.
VDH Procedure for Evaluating Immunization Knowledge and Skills of Vaccinators
Initial training for administering ALL vaccines for MRC Vaccinators(see below): Providing immunizations against vaccine preventable diseases is a critical skill. Therefore, all MRC volunteers eligible to provide immunizations by their licensing, as listed above, must complete all the following training modules.
Note: In an urgent situation, Just in Time Training (JITT) may need to be deployed as described in this document. The use of JITT should not be used routinely as a substitute for the completion of the training modules.
- Understanding the Basics: TRAIN Course ID# 1065440
- Vaccine Administration: TRAIN Course ID# 1101060
- Responding to Anaphylaxis: TRAIN Course ID# 1095208
- Bloodborne Pathogens: TRAIN Course ID# 1028520
MRC volunteers who will be administering influenza vaccines should complete the above training modules(a-d above) AND the following modules:
- Influenza: TRAIN Course ID# 1065390
- Annual influenza season update (TRAIN Course ID# 1100064) released annually with influenza updates)
Note: The Centers for Disease Control (CDC) recommends offering annual influenza vaccine with SARS-CoV-2 (COVID-19) vaccine if applicable.
MRC volunteers who will be administering SARS-CoV-2 vaccines should complete the basic modules (a-d above) AND the following modules:
- SARS-CoV-2 Trainings:
- Pfizer-BioNTech COVID-19 vaccine: TRAIN Course ID# 1095215 Moderna COVID-19 vaccine: TRAIN Course ID# 1095345
- COVID-19 Vaccine InterimCOVID-19 Immunization Schedule for 6 Months of Age and Older (https://www.cdc.gov/vaccines/covid-19/downloads/COVID-19-immunization-schedule-ages-6months-older.pdf)
b. How to use an epinephrine autoinjector: TRAIN Course ID# 1095208
*MRC volunteers may be assigned to review additional modules if Novavax or other SARS-CoV-2 vaccine is to be administered.
Note: All vaccinators must complete all training modules and pass with a score of at least 80% on the module post-tests and complete the skills assessment portion prior to administering vaccines.
Initial training for administering mpox vaccines (ONLY) for MRC Vaccinators:
- Understanding the Basics: TRAIN Course ID# 1065440
- Vaccine Administration: TRAIN Course ID# 1101060
- How to use an epinephrine autoinjector: TRAIN Course ID# 1095208
- JYNNEOS Intradermal (Links to CDC): TRAIN Course ID# 1105563
- Intradermal Vaccination Administration: TRAIN Course ID# 1105563
Initial training for MRC volunteers who will be providing adolescent school-required vaccines must include:
- The Initial Training (a-d modules above) as listed under the general training requirements.
- Tdap: TRAIN Course ID# 1065716
- HPV: TRAIN Course ID# 1067205
- Meningococcal: TRAIN Course ID# 1066729
Note: Adolescents may require additional vaccines if they are not currently up to date. Coordination with the clinical lead is crucial in identifying additional training requirements prior to a vaccination event.
Although training prior to planned exercises is expected, emergency situations may arise and necessitate the use of “just-in-time training” (JITT). When possible, JITT should include:
- Infectious disease targeted by the vaccine,
- Contraindications or precautions for the vaccine,
- Administration route and technique/skills verification,
- Review of emergency procedures, including responding to anaphylaxis and vasovagal events, and
- OSHA considerations for vaccination.
The following courses have been provided as a resource that will allow the district to respond to a wide variety of vaccine preventable disease outbreaks or prevention exercises. Consultation with the expert clinical lead for the event is critical to identify the appropriate course assignment to safely respond to the identified event. A complete listing of additional modules that are current in TRAIN includes the following:
|Topic||Revision date||TRAIN Course ID#|
|Understanding the Basics||2/2023||1065440|
|Vaccine Storage & Handling||1/2023||1065485|
|Vaccines for Children (VFC)||1/2023||1101056|
|Pfizer-BioNtech||Links to CDC||1095215|
|Moderna||Links to CDC||1095345|
|Novavax||Links to CDC||1107395|
|Vaccine Interim COVID-19 Immunization Schedule for 6 Months of Age and Older||Links to CDC|
|JYNNEOS intradermal||Links to CDC||1105563|
|ACAM2000||Links to VDH||1105807|
|How to use an epinephrine autoinjector||1095208|
Safety of the volunteer vaccinators and the public is paramount. The resources below have been provided to assist with that effort. Consultation with the expert clinical lead for the event is critical for identifying the appropriate courses for the event. This list should not be considered all-inclusive. A unique pathogen response may require additional training. A listing of additional modules that may be taken depending on the vaccinator response efforts are as follows:
|Topic||Revision date||TRAIN Course ID#|
|Needle stick prevention||1101015|
|Intradermal Vaccination Administration||1105563|
|Intramuscular injection skills||1096822|
|Blood borne Pathogens||1028520|
|CDC: Comfort and Restraint Techniques||1103883|
|CDC: Intramuscular (IM) Injection: Sites||1102625|
|VDH: Vastus Lateralis Intramuscular Injection||1103885|
|CDC: Intramuscular (IM) Injection: Supplies for Adults||1103882|
- Annual training for COVID-19 and influenza vaccinators who have completed the initial training (a-d modules) must include:
- Current flu season training module update and test (TRAIN Course ID# XXXXXX) and knowledge assessment will be provided when CDC MMWR is made available) if they will be administering influenza vaccine,
- Vaccinator must also view the updated versions of the COVID-19 vaccine training modules if they will be administering COVID-19 vaccines.
- Vaccinator must have had a skills verification within 12 months. This can be accomplished by a subject matter professional at a vaccination event or before attending, and
- Verification of vaccinator’s current licensure and CPR certification.
Note: If it has been greater than 12 months since they last vaccinated with the vaccine they are scheduled to administer, vaccinator should review the vaccine module and pass the knowledge assessment with a score of at least 80% prior to administering the vaccine.
2. Maintaining current clinical competency is crucial for patient safety. All vaccine training shall have occurred within 12 months of assignment to administer the vaccine. If training is not completed within 12 months of assignment, the vaccinator would need to retake the initial training modules.
3. The MRC Coordinator or designee is responsible for ensuring the volunteer has passed the knowledge assessment for each module with a score of 80% or higher in TRAIN. If the volunteer does not pass the test the first time, he or she should review the materials and repeat the test. TRAIN will only allow them to retake the test one time; therefore, those who complete the paper assessment may only do so for a total of two times before viewing the module again. After successfully completing the knowledge assessments, the MRC coordinator or designee will provide the volunteer’s name to the district nurse manager or their designee and coordinate the completion of the skills assessment. If the skills assessment is not completed within 12 months of the assignment the vaccinator would need to retake the skills assessment.
4. The skills portion of the test may be administered by an MRC member who is licensed as an RN, MD, DO, Pharmacist or NP, is trained in vaccine administration, and has demonstrated skill competency, as evidenced by documentation by the district IAP, nurse manager, or her designee. The nurse manager or his or her subject matter professional designee is responsible for verifying that the volunteer has the appropriate skills to administer vaccines. The skills checklist (Appendix A) will be used to verify competence. Upon successful completion, the volunteer’s competencies will be documented in the Virginia Volunteer Health System, and they will be assigned to the corresponding group and role.
Additional Training Information
Proper vaccine storage and handling is vital for protecting the vaccine supply. Vaccinators who will serve in roles that include transporting and monitoring the storage of vaccines are required to complete training outlined in the policy developed jointly by Community Health Services (CHS) and the Office of Emergency Preparedness: Maintaining Immunization Cold Chain (note: this link with take you to the CHS policy page on the intranet. You will need to scroll down to the policy and click on it to open the link the policy).
Vaccinator’s First and Last Name: _______________________________________________
|Knowledge Assessment (online)||Date Passed & Initial|
|Understanding the Basics: TRAIN Course ID# 1065440
Vaccine Administration: TRAIN Course ID# 1101060
How to use an epinephrine autoinjector: TRAIN Course ID# 1095208
Responding to Anaphylaxis: TRAIN Course ID# 1095208
Annual influenza update: (TRAIN Course ID# changes annually)
|Pfizer-BioNTech COVID-19 vaccine: TRAIN Course ID# 1095215
Moderna COVID-19 vaccine: TRAIN Course ID# 1095345
Novavax COVID-19 vaccine: TRAIN Course ID# 1107395(only if administering Novavax)
SARS-CoV-2 Vaccines Updates: CDC COVID-19 Vaccine Training Modules andCOVID-19 Vaccine Interim COVID-19 Immunization Schedule for 6 Months of Age and Older
|JYNNEOS intradermal (ID): TRAIN Course ID# 1105563|
|ACAM2000: TRAIN Course ID# 1105807|
|Skills Assessment (In-person)|
|Accommodates language or literacy barriers. Uses language line and/or interpreter as appropriate.|
|Verifies client/parent/caregiver received Vaccine Information Statements for all vaccines to be given, ensures client/parent/caregiver had time to read information and ask questions, and provides an opportunity to discuss side effects.|
|Screens for contraindications, including latex.
|Core Function||Date Passed & Initial|
|Identifies the location of medical protocols and supplies (immunization protocol and district emergency protocol, reporting adverse events to the Vaccine Event Reporting system [VAERS], reference material).|
|Describes appropriate responses to any adverse reaction resulting from vaccine administration, including anaphylaxis and syncope.|
|Identifies the location of epinephrine and/or anaphylaxis kit, its administration technique, and clinical situations where its use would be indicated.|
|Maintains up-to-date CPR certification.|
|Identifies AED location.|
|Understands the need to report client or provider needle stick injuries.|
|Demonstrates knowledge of proper vaccine handling (e.g., maintains and monitors vaccine at recommended temperature and protects from light).|
|Vaccine Preparation||Date Passed & Initial|
|Changes gloves and/or performs hand hygiene|
|Ensures storage unit’s temperature is in proper range when removing vaccine from refrigerator or freezer.|
|Checks expiration date on each vial/pre-filled syringe (vaccine and diluents) before use.|
|Selects correct needle size based on patient age and/or weight, site, and recommended injection technique.|
|Prepares and draws up vaccines in a designated clean medication area that is not adjacent to areas where potentially contaminated items are placed.|
|Maintains aseptic technique throughout, including cleaning the rubber stopper of the vial with alcohol prior to piercing it|
|Reconstitutes vaccine using appropriate diluent (if indicated) and draws vaccine into the syringe prepared according to manufacturer instructions.|
|Prepares a new sterile syringe and sterile needle for each injection. Checks the expiration date on the equipment (syringes and needles) if present.|
|Labels each filled syringe or uses labeled tray to keep multiple syringes identified if needed.|
|Administering Immunizations||Date Passed & Initial|
|Verifies identity of patient. Rechecks the provider’s order or instructions against the vial and prepared syringes if needed.|
|Utilizes proper hand hygiene with every patient, and if using gloves, changes gloves and performs hand hygiene in between each patient.|
|Demonstrates knowledge of the appropriate route for each vaccine (IM, subQ, PO, NS)|
|Positions patient and/or ensures position of child is held with parent’s help.|
|Locates appropriate anatomic landmarks specific for IM or subQ injection and/or correctly identifies injection site (deltoid, vastus lateralis, fatty tissue over triceps).|
|Preps skin in a circular motion with alcohol or antiseptic cleanser. Allows it to dry.|
|Inserts the needle quickly at the appropriate angle to skin (90° IM, 45º or 15° subQ) while controlling the limb with the non-dominant hand.|
|Injects vaccines using steady pressure and withdraws the needle at angle of insertion.|
|Applies gentle pressure to the injection site for several seconds with a dry, sterile pad, cotton ball, bandaid, etc.|
|Properly disposes of needle, syringe, and live vaccine vials in a sharps container. Disposes of other vials in trash. Verbalizes proper disposal of all medical and biohazard waste, including safe transport of sharps containers to and from offsite clinics. Demonstrates replacement of sharps containers when ¾ full, procedure for “sealing” the containers, disposing in hazardous waste boxes/bins, and how to package hazardous waste bins/boxes for pick up.|
|Demonstrates appropriate administration of intradermal injection (JYNNEOS Intradermal Vaccine Checklist)|
|Demonstrates appropriate administration of intramuscular injection|
|Demonstrates appropriate administration of nasal immunization|
|Demonstrates appropriate administration of oral immunization|
|Demonstrates appropriate administration of subcutaneous injection|
|Records Procedures||Date Passes & Initials|
|Fully documents each vaccination in patient chart; date given, lot number, expiration date, manufacture, site, VIS date, name/initials|
|If applicable, demonstrates ability to use state/local immunization registry or computer to call up patient record, assess what is due today, and update computerized immunization history.|
|Asks for and updates patient’s vaccination record and reminds them to bring it to each visit.|
Evaluator’s Name and Signature. The evaluator shall date and initial all appropriate training items.
|Knowledge Assessment Evaluator’s Printed Name||Evaluator’s Signature||Evaluator’s initials|
|Skill Assessment Evaluator’s Printed Name||Evaluator’s Signature||Evaluator’s initials|
Code Citation and References:
- In accordance with § 54.1-3001 of the Code of Virginia, a nursing student, while enrolled in an approved nursing program, may perform tasks that would constitute the practice of nursing. The student shall be responsible and accountable for the safe performance of those direct client care tasks to which he has been assigned.
- Faculty shall be responsible for ensuring that students perform only skills or services in direct client care for which they have received instruction and have been found proficient by the instructor. Skills checklists shall be maintained for each student.
- Faculty members or preceptors providing onsite supervision in the clinical care of clients shall be responsible and accountable for the assignment of clients and tasks based on their assessment and evaluation of the student’s clinical knowledge and skills. Supervisors shall also monitor clinical performance and intervene if necessary for the safety and protection of the clients.
- Clinical preceptors may be used to augment the faculty and enhance the clinical learning experience. Faculty shall be responsible for the designation of a preceptor for each student and shall communicate such assignment with the preceptor. A preceptor may not further delegate the duties of the preceptorship.
- Preceptors shall provide to the nursing education program evidence of competence to supervise student clinical experience for quality and safety in each specialty area where they supervise students. The clinical preceptor shall be licensed as a nurse at or above the level for which the student is preparing.
A prescriber may authorize, pursuant to a protocol approved by the Board of Nursing, the administration of vaccines to adults for immunization, when a practitioner with prescriptive authority is not physically present, by (i) licensed pharmacists, (ii) registered nurses, or (iii) licensed practical nurses under the supervision of a registered nurse. A prescriber acting on behalf of and in accordance with established protocols of the Department of Health may authorize the administration of vaccines to any person by a pharmacist, nurse, or designated emergency medical services provider who holds an advanced life support certificate issued by the Commissioner of Health under the direction of an operational medical director when the prescriber is not physically present. The emergency medical services provider shall provide documentation of the vaccines to be recorded in the Virginia Immunization Information System. In addition, this section shall not prevent the administration or dispensing of drugs and devices by persons if they are authorized by the State Health Commissioner in accordance with protocols established by the State Health Commissioner pursuant to § 32.1-42.1 when (i) the Governor has declared a disaster or a state of emergency or the United States Secretary of Health and Human Services has issued a declaration of an actual or potential bioterrorism incident or other actual or potential public health emergency; (ii) it is necessary to permit the provision of needed drugs or devices; and (iii) such persons have received the training necessary to safely administer or dispense the needed drugs or devices. Such persons shall administer or dispense all drugs or devices under the direction, control, and supervision of the State Health Commissioner.
Use of National Guard and Active Duty Military:
Active Duty Military
DHP regulations may not prevent the performance of the duties of any active duty health care provider in active service in the army, navy, coast guard, marine corps, air force, or public health service of the United States at any public or private health care facility while such individual is so commissioned or serving and in accordance with his official military duties. (§ 54.1-2901. Exceptions and exemptions generally.)
Any commissioned or contract medical officers or dentists serving on active duty in the United States armed services and assigned to duty as practicing commissioned or contract medical officers or dentists at any military hospital or medical facility owned and operated by the United States government shall be deemed to be licensed pursuant to this title. (§ 54.1-106. Health care professionals rendering services to patients of certain clinics and administrators of such services exempt from liability.)
Military Medical Personnel
Defined as: “an individual who has recently served as a medic in the United States Army, medical technician in the United States Air Force, or corpsman in the United States Navy or the United States Coast Guard and who was discharged or released from such service under conditions other than dishonorable.” (§ 2.2-2001.4. Military medical personnel; program.)
Military medical personnel may practice and perform certain delegated acts that constitute the practice of medicine or nursing, reflecting the level of training and experience of the military medical personnel and under the supervision of a licensed physician or podiatrist. (§ 2.2-2001.4. Military medical personnel; program.) (§ 54.1-2901. Exceptions and exemptions generally.)
Veenema, T.G.(2006). Expanding educational opportunities in disaster and emergency
preparedness for nurses. Nursing Education Perspectives 27(2), 93-99.
Effective Date: May 2023
Review Date: March 2025 Revision Date: May 2025
- Pediatric Vaccinations Resources Section VI : Note: Pediatric vaccinations should only be administered by vaccinators that have been previously trained and have experience in vaccinating pediatrics. These materials are not for vaccinators that do NOT have that previous experience.
- **Click here to view the current VDH: TRAINING AND PREPARATION FOR ADMINISTERING COVID-19 VACCINATION**
- Registered nurses, nurse practitioners, physician assistants, and/or physicians can attend training.
- Two vaccines may be used for the prevention of Mpox virus infection:
- JYNNEOS (also known as Imvamune or Imvanex), is licensed (or approved) by the U.S. Food and Drug Administration (FDA) for the prevention of Mpox virus infection, and
- ACAM2000, licensed (or approved) by FDA for use against smallpox and made available for use against Mpox under an Expanded Access Investigational New Drug application.
QUESTIONS / EXPERIENCING DIFFICULTY
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Updated on 7/6/2023