Vaccines for Children Program (VFC) For State Immunization Projects

On this page:

• Official forms
• "Best Practice" forms
  • State of Utah's version of “Vaccine Management, Handling and Storage Details for Vaccines”
• Screen-reader device (text-only) versions of forms

Related pages:

• VFC-AFIX Provider Satisfaction Survey Examples

1. Certification of Capacity to Store Varivax Form (.pdf)
2. Disenrollment Form (.pdf)
3. Hepatitis A Recommendations - Providers (.pdf)
4. Hepatitis A Recommendations - Public Sector (.pdf)
5. Immunization Record & History Form (.pdf)
6. Vaccine Return or Transfer Report Form (.pdf)
7. Vaccine Usage Log Form (.pdf)
8. Annual recertification process letter (.pdf)
9. Suggestions for Developing Estimates for VFC Provider Profile Form (.pdf)
10. Provider MCV-4 Letter (.pdf)
    

Please note: These forms are provided as examples of "best practices". We invite all grantees to submit their examples/best practices to Jack Nemecek at JNemecek@cdc.gov. The best of those submitted will be shared on this website.

These files are provided in the original formats so that you can modify them for your needs.

	.rtf format	Combined Measles, Mumps, Rubella, and Varicella (MMRV) Vaccine (from California VFC)
	.rtf format	Vaccine Direct Shipped (Frozen) Request Form (view the .pdf version)
	.doc format	Power Outage Report (from Arizona VFC)
	.doc format	Refrigerators/Freezers Storing Vaccines Incident Report of Power Outage/Failure
	.doc format	Vaccine Management and Relocation Guidelines (from Oregon immunization program) (Text-only version for screen-readers)
	.xls format	Vaccine Losses spreadsheet (from Nevada VFC) (HTML format for screen-readers)
Tdap Sample Letters for Providers Samples of letters that California has done up to notify various government and provider entities about Tdap, and why it is now part of the program
	.pdf format	Tdap sample letter to providers (1 page) (Text-only version for screen-readers not available)
	.pdf format	Tdap sample memo to providers (6 pages) including: summary, background, recommendations for vaccine use, potential vaccine reactions, contraindications and precautions to Tdap, ordering and billing, etc.   (Text-only version for screen-readers not available)
	.pdf format	Tdap sample letter to health officers and immunization coordinators (1 page) (Text-only version for screen-readers not available)

Special Note: The State of Utah recently published their own version of “Vaccine Management, Handling and Storage Details for Vaccines”, and has agreed to make the art work for this document available to interested Grantees that would like a document that serves as your State’s guidance on this issue. Please email IMMUNEUTAH@UTAH.GOV, or call the Utah Immunization Program at (801) 538-9450, or consult their website: www.immunize-utah.org

All of the above forms are listed similarly below but in text-only format for screen-reader devices. (All forms are provided as examples only.)

Should you need assistance with these screen-reader device versions, please contact NIPINFO@cdc.gov.

1. Certification of Capacity to Store Varivax Form (text-only for screen-reader devices)
2. Disenrollment Form (text-only for screen-reader devices)
3. Hepatitis A Recommendations - Providers (text-only for screen-reader devices)
4. Hepatitis A Recommendations - Public Sector (text-only for screen-reader devices)
5. Immunization Record & History Form (text-only for screen-reader devices)
6. Vaccine Return or Transfer Report Form (text-only for screen-reader devices)
7. Vaccine Usage Log Form (text-only for screen-reader devices)
8. Annual recertification process letter (text-only for screen-reader devices)
9. Suggestions for Developing Estimates for VFC Provider Profile Form (text-only for screen-reader devices)
10. Provider MCV-4 Letter (text-only for screen-reader devices) NEW as of July 8, 2005

• Power Outage Report  (text-only for screen-reader devices)
• Vaccine Losses spreadsheet  (HTML format for screen-reader devices)
• Refrigerators/Freezers Storing Vaccines Incident Report of Power Outage/Failure for screen-reader devices (.txt format)

This page last modified on July 27, 2006