Vaccines for Children
Program (VFC)
For
State Immunization Projects
|
|
VFC
Forms Note:
All forms are provided as examples only.
On
this page:
Related
pages:
Example
Forms: |
Thanks
to the State of California Immunization Program for making these
forms available. |
Most
of these forms are provided in .pdf format
which can be printed out and filled in
for submission. Those provided in .doc
format can be opened and filled in online. (All
forms are provided as examples only. Use
them as models for your own needs.) |
- Certification
of Capacity to Store Varivax Form (.pdf)
-
Disenrollment
Form (.pdf)
- Hepatitis
A Recommendations - Providers (.pdf)
- Hepatitis
A Recommendations - Public Sector (.pdf)
-
Immunization
Record & History Form (.pdf)
-
Vaccine
Return or Transfer Report Form (.pdf)
-
Vaccine Usage
Log Form (.pdf)
- Annual
recertification process letter (.pdf)
-
Suggestions
for Developing Estimates for VFC Provider
Profile Form (.pdf)
-
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) |
"Vaccine
Management..." from State of Utah: |
|
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 |
Screen-reader
device versions |
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.
- Certification
of Capacity to Store Varivax Form (text-only
for screen-reader devices)
- Disenrollment
Form (text-only for screen-reader
devices)
- Hepatitis
A Recommendations - Providers (text-only
for screen-reader devices)
- Hepatitis
A Recommendations - Public Sector (text-only
for screen-reader devices)
- Immunization
Record & History Form
(text-only for screen-reader devices)
- Vaccine
Return or Transfer Report Form (text-only
for screen-reader devices)
- Vaccine
Usage Log Form (text-only
for screen-reader devices)
- Annual
recertification process letter (text-only
for screen-reader devices)
-
Suggestions
for Developing Estimates for VFC Provider
Profile Form (text-only
for screen-reader devices)
-
Provider
MCV-4 Letter (text-only
for screen-reader devices)
NEW
as of July 8, 2005
|