MODULE 3 – Provider Recruitment and Enrollment

http://www.cdc.gov/vaccines/programs/vfc/default.htm

Overview

The success of the VFC Program is due in large part to the participation of private providers in the program. The VFC Program was created to increase access to immunizations outside of public health department clinics in order to allow eligible children to remain in their medical homes for immunizations to the extent possible. Therefore, maintaining participation of private immunization providers is critical to ensuring that VFC-eligible children have access to vaccines in their medical homes.

Please note: The "FAQs for State/Territory VFC Projects" section on the VFC website contains additional guidance on provider enrollment not contained in this module. Please refer to 
http://www.cdc.gov/vaccines/programs/vfc/projects/default.htm#faq

Provider Recruitment

State and local immunization programs should continue to enroll healthcare providers into the VFC program by identifying and recruiting new providers, including nontraditional providers who serve adolescents—e.g., long-term juvenile correctional facilities, family planning and STD clinics, adolescent medicine practices, and OB/GYN practices. Particularly relevant for these nontraditional providers, grantees have the discretion to allow specialty providers to limit their VFC participation to specific vaccines recommended for adolescents.

Recruitment efforts should also be targeted to providers who may have initially declined enrollment, who have not been previously recruited, or who are newly licensed or newly established within the grantee's area. It is understood that not all providers who serve children will be enrolled in the VFC program because some serve only children who are fully insured and are not VFC eligible.

Grantees should have written policies, protocols, and procedures to recruit and enroll providers into the VFC program. These guidance documents should include methods for accomplishing the following:

•	Identifying practicing providers. This can be done through collaboration with medical societies, state licensing boards and the state Medicaid agency. With assistance from these organizations, grantees can better identify the subset of providers who may be immunizing children and who are not enrolled in the VFC program.
•	Prioritizing potential VFC providers for contact. Prioritization criteria may include practice size, age of patients, location of practice, or previous contact with the provider regarding VFC enrollment. Newly licensed providers and providers located in “pockets of need” or who have large panels of Medicaid children should be given priority over providers who have declined to participate in the VFC program in the past.
•	Scheduling recruitment appointments with providers based on the priority criteria.
•	Documenting results of recruitment efforts and following up as needed with all providers.

Provider Enrollment

A provider's understanding of how the VFC program works is critical to maintaining the integrity of the VFC program. ("Provider" includes all appropriate office staff.) Therefore, it is essential that VFC grantees have a strong and ongoing provider education component. Provider education must begin during the recruitment and enrollment process and continue with every provider contact.  All providers enrolling in the VFC program must have an initial VFC enrollment site visit.  The purpose of this visit is to ensure that the provider and office staff are educated on the VFC program requirements and have the appropriate resources to implement the VFC program requirements.  Education regarding the VFC program should be structured according to the requirements for provider enrollment. These are explained below.

Two forms must be completed by each VFC provider at enrollment and be kept up-to-date thereafter:

1.	Provider Profile form (see Appendix 2). The Provider Profile form requires information on the VFC-eligible children in the practice. It is used to evaluate vaccine orders and ensure that VFC-funded vaccine is being administered only to VFC-eligible children. States may collect this information on a different form as long as the required information is included. Each grantee is responsible for the accuracy and reliability of the Provider Profiles submitted by VFC-enrolled practitioners. For all VFC enrolled providers, enrollment figures must be based on actual data. The Provider Profile must be updated annually. For further information on determining VFC eligibility, please refer to Module 2.

Provider Enrollment form. The Provider Enrollment form is the provider's agreement to comply with all the conditions of the VFC program. This form must be signed annually. The medical director or equivalent in a group practice with many providers must sign the Provider Enrollment form for the entire group. All other providers within the practice must be listed on the enrollment form. CDC defines the compliance requirements of the VFC program. Grantees should create their own forms, but the form must contain all the requirements listed below. A grantee may not mandate additional requirements for provider enrollment in the VFC program without formal approval from CDC. The process to request additional requirements for participation in the VFC program is outlined later in this module.

 Provider Enrollment Requirements
Each provider must agree to the following requirements to participate in the VFC program. To help with communication of these requirements to the provider, educational goals are listed after each requirement. These educational goals must be communicated to providers at the time of initial enrollment and during the renewal process. It is the responsibility of the grantee's VFC staff to educate the provider and office staff on how to implement each requirement.

1)	Screen patients at all immunization encounters for eligibility and administer VFC-purchased vaccine only to children who are 18 years of age or younger who meet one or more of the following categories: 
a)	Are federally vaccine-eligible 
i)	are an American Indian or Alaska Native; or 
ii)	are enrolled in Medicaid; or
iii)	have no health insurance; or
iv)	are underinsured: Children who have commercial (private) health insurance but the coverage does not include vaccines, children whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only), or children whose insurance caps vaccine coverage at a certain amount (once that coverage amount is reached, these children are categorized as underinsured). Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).
b)	Are considered state vaccine-eligible under criteria determined by each grantee (e.g., underinsured children not served through an FQHC or RHC) for administration of pediatric vaccine purchased with Section 317 or other state funds.

Provider Education Goals for this requirement: 
By the end of the enrollment or education session, the provider and staff will understand

•	The eligibility requirements for the VFC program;
•	That the grantee will monitor the screening for eligibility requirement during the VFC site visit by conducting a random sample of 30 children 0-18 yrs.  If a combination visit (VFC/AFIX) is being conducted then 30 records from the AFIX sample can be utilized.  If there are not 30 records in the AFIX sample use, those charts and systematically select additional records from the 0-18 years age group until 30 records for the eligibility screening sample is reached.   Include both VFC and non-VFC eligible children in the sample.  If a provider does not have 30 children in the 0-18 years of age group, review all charts.  Please refer to Appendix 6 for additional information on how to select and implement the chart review for eligibility screening.
•	Where to refer underinsured children to obtain VFC vaccine;
•	How and when to document the initial screening on the appropriate screening form and retain in the child's medical record;
•	That after the initial VFC screening form is completed, the child should, at a minimum, be verbally screened at each subsequent immunization visit for continued eligibility;

•	That the initial screening form must be updated when eligibility changes (see Appendix 3). A new screening form may be completed or the initial screening form may be updated with the following information:
	◦   Date of screening
		◦   Reason for change in eligibility 

2)	Comply with immunization schedules, dosages, and contraindications that are established by the Advisory Committee on Immunization Practices (ACIP) and included in the VFC program unless:
a)	In the provider's medical judgment, and in accordance with accepted medical practice, the provider deems such compliance to be medically inappropriate;
b)	The particular requirements contradict state law, including laws pertaining to religious and other exemptions.

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	The current ACIP recommendations and how to locate these recommendations and the VFC resolutions;
•	The process the grantee uses to notify VFC-enrolled providers about changes to the VFC program;
•	The state laws related to vaccination requirements and acceptable vaccine exemptions;
•	The true contraindications for each VFC vaccine.

3)	Maintain all records related to the VFC program for a minimum of 3 years, or longer if required by state law, and make these records available to public health officials, including the state or Department of Health and Human Services, (DHHS) upon request. 

Provider Education Goals for this requirement:
By the end of the enrollment or education session the provider and staff will understand

•	All records related to the VFC program must be maintained for the required time period. These records include (but are not limited to) patient screening forms, temperature logs, and any other reports or documents required by the grantee.

4)	Immunize eligible children with VFC-supplied vaccine at no charge to the patient for the vaccine

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	Patients or Medicaid agencies cannot be billed for the cost of VFC vaccine or state-supplied vaccine;
•	Borrowing VFC vaccine to administer to a non-VFC eligible patient can occur only in rare unplanned situations.
•	VFC-enrolled providers are expected to maintain an adequate inventory of vaccine for their non-VFC-eligible patients.
•	VFC vaccine cannot be used as a replacement system for a provider’s privately purchased vaccine inventory.
•	The provider must assure that VFC vaccine supply is adequate to meet the needs of the provider’s VFC-eligible patients and that borrowing VFC vaccine will not prevent a VFC-eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible child.  
•	Borrowing would occur only when there is lack of private-stock vaccine due to unexpected circumstances such as a delayed vaccine shipment, vaccine spoiled in-transit to provider, or new staff that calculated ordering time incorrectly.  
•	Every time a VFC vaccine is borrowed the provider must complete the VFC Vaccine Borrowing Report form (see page 11 of this module). Once the borrowed VFC vaccine is replaced with private stock vaccine, that date should be entered on the form and the completed form sent to the immunization program.  The provider should keep a copy of the completed form for their records.
•	If a provider borrows privately purchased vaccine to administer to a VFC-eligible child due to a situation where no VFC vaccine is available, it is not necessary for a provider to document that borrowing or replacement on the CDC form.   The provider may consider developing a method of record keeping for this type of borrowing to ensure that the private-stock vaccine is replaced or if questions arise about use of VFC vaccine.

Please note: Grantees must use the CDC form  and follow the grantee requirements located at the end of this module. Grantees will be required to provide aggregate information on borrowing activity beginning with calendar year 2008 to CDC. This information will be reported in the VFC Management Survey beginning in March 2009.  Additionally, as requested by CDC, grantees may need to provide information on the reasons for borrowing vaccine and the length of time required to replace the doses of VFC vaccine.

5)	Not charge a vaccine administration fee to non-Medicaid VFC-eligible children that exceeds the administration fee cap of $____ per vaccine dose (state to fill in amount for administration fee. See Appendix 4 for maximum regional charges). For Medicaid VFC-eligible children, accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans.

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	The maximum amount that can be charged for administration of each VFC vaccine to non- Medicaid VFC-eligible children;
•	How to bill for the administration fee for VFC-eligible children enrolled in Medicaid.

6)	Not deny administration of a federally purchased vaccine to an established patient because the child's parent/guardian/individual of record is unable to pay the administration fee.

Please note: The term “established patient” applies only to private providers enrolled in the VFC program.   CDC considers public providers the safety net providers for the VFC population and they must administer VFC vaccine to any VFC-eligible children who present for immunization services at their facilities.

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	This requirement applies to VFC vaccines as well as any other vaccines purchased through the CDC federal contracts when the eligible child's family/guardian is unable to pay the administration fee;
•	The only fee that must be waived is the administration fee. Other visit or office fees may be charged as applicable.

7)	Distribute the most current Vaccine Information Statements (VIS) each time a vaccine is administered and maintain records in accordance with the National Childhood Vaccine Injury Compensation Act (NCVICA), which includes reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS).

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	How to obtain the most current VIS forms;
•	The use of VIS forms applies to all vaccines included in the NCVICA or purchased through federal contracts;
•	The recordkeeping requirements for the NCVICA;
•	How to report adverse reactions to VAERS.

8)	Comply with the requirements for vaccine ordering, vaccine accountability, and vaccine management. Agree to operate within the VFC program in a manner intended to avoid fraud and abuse.

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	The vaccine management practices required for participation in the VFC program;
•	The grantee's policy regarding replacing vaccine lost due to mismanagement;
•	How to order vaccine and which documents must be submitted with vaccine orders.

Please note: When developing their requirements for vaccine ordering, accountability and management, grantees must include all required vaccine management responsibilities listed under “Provider Vaccine Management Requirements” in Module 6 “Vaccine Management” of this VFC Operations Guide.

Other items that grantees may include under this requirement without prior approval from CDC include:

•	Any grantee requirements related to the process for ordering VFC vaccine, including timing and amount of order as well as submission of any documents to demonstrate that VFC vaccine was provided only to VFC-eligible children within the provider's practice (accountability).
•	Any requirement to replace, dose-for-dose, all VFC vaccine lost due to mismanagement within the provider’s practice.

Additional activities require prior approval from CDC (see next section on how to submit additional requirements for approval). 

9)	The grantee or the provider may terminate this agreement at any time for personal reasons or failure to comply with these requirements. If providers choose to terminate the agreement, they agree to properly return any unused VFC vaccine.

Provider Education Goals for this requirement: 
By the end of the enrollment or education session the provider and staff will understand

•	Situations that would terminate their participation in the VFC program;
•	How to return unused VFC vaccine;
•	How to discontinue enrollment from the VFC program if the practice's situation changes.

CDC no longer provides a template for the Provider Enrollment form; grantees must create their own Provider Enrollment forms using the nine requirements outlined above. The only requirements that grantees may customize are #1, #5 and #8. Items #1 and #5 allow the grantee to select the most appropriate wording, and requirement #8 allows grantees to select a limited number of additional accountability requirements without going through the CDC approval process. States may not impose additional requirements for enrollment without prior approval from CDC (see below for process to request additional provider requirements).

Process for Requesting and Approving Additional Provider Requirements for VFC Participation

1.	Immunization program manager submits written request to the Program Operations Branch VFC policy coordinator (electronic submission is acceptable and preferred) for adding a new requirement to the VFC provider enrollment agreement. The written request must include the following information:
a.	New requirement as it would appear on the enrollment form;
b.	Rationale for the new requirement, including why it would strengthen or enhance the grantee's VFC program;
c.	Proposed start date for the new requirement together with a written plan for implementing the new requirement for both new and existing VFC providers;
d.	Any potential negative impact to VFC program.

2.	On a regular basis, the VFC Policy Coordinator will review the pending requirement requests with the Director or Deputy Director of the Immunization Services Division, CDC legal counsel, and other officials as necessary to approve, disapprove or request further information before making a decision on the request and will communicate the decision to the project officer.

3.	The approval or disapproval will be communicated to the grantee by the project officer and/or the VFC policy coordinator.

Please note for 2007: All grantees were required to submit a copy of their 2008 Provider Enrollment forms to the VFC Policy Coordinator no later than October 1, 2007. All grantees should have submitted their forms even if the grantee's form contained only the nine federal requirements. All grantees will receive written confirmation that their enrollment forms were received and approved. 

Special Populations

The VFC program recognizes several situations in which the use of special VFC eligibility screening forms may improve the efficiency of the provider's or clinic's implementation of the VFC program or are necessary because of the individual's situation. If a provider exclusively serves patients from birth through 18 years who are American Indian or Alaska Native or serves only Medicaid-enrolled patients, he/she may use the appropriate Comprehensive Certification Form (see Appendix 3). Please remember that these Comprehensive Certifications are acceptable substitutes for individual VFC screening forms only if that provider's patient population is 100% American Indian or Alaska Native or Medicaid enrolled. This certificate must be signed annually and verified against the most current provider profile.

Please Note: Use of comprehensive certification forms is optional at a grantee's discretion. A grantee may require providers to screen all children individually for VFC eligibility even if the provider's population is 100% American Indian/Alaska Native, or Medicaid enrolled.

Another population that requires a specialized VFC screening form is minors under 19 years of age without insurance status presenting at family planning clinics. A person under 19 years of age who may have insurance but because of the confidential circumstances for seeking services does not have access to that insurance coverage is considered uninsured for the purposes of the VFC program. The family planning clinic must screen these adolescents for VFC eligibility using the form "Patient Eligibility Screening Record Vaccines for Children Program in Family Planning Clinics" (see Appendix 3). In addition, each family planning clinic must document all VFC vaccines administered to unaccompanied minors without insurance information on the administration log titled "Family Planning Clinic Unaccompanied Minor without Insurance Information VFC Vaccine Log" (see Appendix 3). The completed logs should be submitted to the immunization program on a monthly basis. Please note that the VFC program does not in any way regulate the issue of medical consent for the provision of medical care to minors. It is assumed that the clinic provides any such care in conformance with the state's medical consent laws as they pertain to minors. Provision of VFC vaccine to unaccompanied minors without insurance status in family planning clinics is optional at a grantee's discretion and in compliance with the state's medical consent laws as they pertain to minors.

Please note: In addition, to reviewing a family planning clinic's monthly Family Planning Clinic Unaccompanied Minor without Insurance Information VFC Vaccine log, each grantee must provide aggregate information annually on the number of children without insurance status who are provided VFC vaccine in family planning clinics, including the type and number of VFC vaccines administered to these children. CDC will begin collecting this information through a new question in the 2007 VFC Management Survey that is due March 1, 2008. 

Please note: Grantees can develop their own system to collect the information required on the Family Planning Clinic Unaccompanied Minor without Insurance Information VFC Vaccine Log (see Appendix 3). The template is provided as an example, but use of the template is not required.  If a grantee develops its own system, the grantee must collect all information shown on template.

At times VFC-eligible children receive their health care in a bordering state instead of their state of residency.  This usually occurs due to access to health care issues. Grantees should have Memoranda of Understanding (MOUs) in place with neighboring states to assure VFC-eligible children have access to VFC vaccine within their medical homes.  Providers must be educated that if the provider administers VFC vaccine to a Medicaid VFC-eligible child from a neighboring state, the provider must be a Medicaid enrolled provider for the state where the Medicaid VFC-eligible child resides in order to receive reimbursement for the administration fee from the neighboring state’s Medicaid program.   Please refer to Appendix 3 for a sample border states MOU.

Grantee Requirements for Monitoring and Reporting Borrowing of VFC Vaccine 
Grantees must develop a method for monitoring and maintaining vaccine borrowing reports to allow for timely and accurate reporting to CDC on the number of providers borrowing VFC vaccine, the number of non-VFC eligible children receiving VFC vaccine and the number of VFC vaccines borrowed by type of vaccine. This information will be collected and reported in the VFC Management Survey due annually on March 1st.

•	The first report on 2008 borrowing occurrences will be reported in the 2009 VFC Management Survey.
•	If requested by CDC, grantees should be able to provide data on reasons for borrowing and average length of time to replace borrowed VFC stock  
•	Since borrowing of VFC vaccine should be a rare occurrence, grantees must follow-up with providers that submit multiple reports in a single year, and the follow-up should include a site visit to provide education and assess the immunization delivery system within the practice to determine if changes must be implemented to eliminate the need for frequent borrowing of VFC vaccine. Providers should be notified that the state may ask for information validating that borrowed VFC vaccine was replaced by asking for a copy of  the invoice for the private stock vaccine used to replenish the borrowed VFC vaccine to determine if the invoice date corresponds with the replacement date on the borrowing report.

Who Should Sign the VFC Provider Enrollment Form?

Section 1928 (c) (1) (A) of the Social Security Act (42 U.S.C. 1396s (c) (1) (A) states that the following providers qualify to be VFC program-registered providers: those healthcare providers "licensed or otherwise authorized for administration of pediatric vaccines under the law of the State in which the administration occurs" (subject to section 333 (e) of the Public Health Service Act, which authorizes members of the Commissioned Corps to practice).
The VFC statute follows state law in qualifying practitioners as VFC providers. The term “authorized for administration of pediatric vaccines” is intended to mean authorized to “prescribe” vaccines. Therefore, only providers authorized to prescribe vaccines under state law should be the official VFC program-registered providers. However, other providers authorized to administer vaccines can operate under the supervision of a prescribing VFC provider and should be listed on the Provider Enrollment Form.

SAMPLE COMPLETED VFC Vaccine Borrowing Report  
Guidance:
VFC-enrolled providers are expected to maintain an adequate inventory of vaccine for their non-VFC-eligible patients.  VFC vaccine cannot be used as a replacement system for a provider’s privately purchased vaccine inventory.  The provider must assure that VFC vaccine supply is adequate to meet the needs of the provider’s VFC-eligible patients and that borrowing VFC vaccine will not prevent a VFC-eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible child.  Borrowing would occur only when there is lack of private-stock vaccine due to unexpected circumstances such as a delayed vaccine shipment, vaccine spoiled in-transit to provider, or new staff that calculated ordering time incorrectly.  The reason cannot be provider planned borrowing from VFC stock. 
Directions for use of this form:

For each VFC vaccine borrowed all information in that row of the table must be completely filled out

It is acceptable to use “     “  to indicate the above child received another VFC vaccine as long as the additional vaccines are identified

It is also acceptable for each VFC vaccine borrowed and administered to an individual to complete all information in each row of the table 

  Circle or write in reason for no private stock was available

When a provider has borrowed VFC vaccine for administration to a non-VFC-eligible child, this form must be COMPLETELY FILLED OUT for each non-VFC-eligible child receiving a VFC vaccine. Each VFC vaccine a child receives must be listed on a separate row.  As soon as the borrowed doses of VFC vaccine are replaced by private stock vaccine, the form must be faxed to the immunization program:

Attention: Florence Nightingale
Fax Number: 555-444-3333
Time period of 10/19/2007 to 10 /21/2007
Clinic/Provider Name: ABC Clinic
Office Contact Name: Suzie Que
Telephone Number/ fax: 555-444-2211/555-444-9889
E-mail address: Que@abc.com
VFC Number: 21122
Vaccine  Borrowed	Patient Name/Patient Identifier	DOB	Date Borrowed	                                                                                                    Reason no private stock vaccine was available	Date vaccine returned to VFC stock	
DTaP	Shirley Temple	08/01/20007	10/19/2007	1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)	10/21/2007	
IPV	“                   “	“        “	“          “  	1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)	10/21/2007	
DTaP	Mickey Rooney	08/15/2007	10/19/2007	1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)	10/21/2007	
IPV	Mickey Rooney	08/15/2007	10/19/2007	1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)	10/21/2007	
				1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)		
"I hereby certify, subject to penalty under the False Claims Act (31 U.S.C. § 3730) and other applicable Federal and state law, that VFC vaccine dose borrowing and replacement reported on this form has been accurately reported and conducted in conformance with VFC provisions for such borrowing and further certify that all VFC doses borrowed during the noted time period have been fully reported on this form.
"Provider Name:	_Dr. Sam Who_____Provider Signature: _Dr. Sam Who____Date: 10/21/2007   

VFC Vaccine Borrowing Report
Guidance:
VFC-enrolled providers are expected to maintain an adequate inventory of vaccine for their non-VFC-eligible patients.  VFC vaccine cannot be used as a replacement system for a provider’s privately purchased vaccine inventory.  The provider must assure that VFC vaccine supply is adequate to meet the needs of the provider’s VFC-eligible patients and that borrowing VFC vaccine will not prevent a VFC-eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible child.  Borrowing would occur only when there is lack of private-stock vaccine due to unexpected circumstances such as a delayed vaccine shipment, vaccine spoiled in-transit to provider, or new staff that calculated ordering time incorrectly.  The reason cannot be provider planned borrowing from VFC stock. 

Directions for use of this form:
When a provider has borrowed VFC vaccine for administration to a non-VFC-eligible child, this form must be COMPLETELY FILLED OUT for each non-VFC-eligible child receiving a VFC vaccine. Each VFC vaccine a child receives must be listed on a separate row.  As soon as the borrowed doses of VFC vaccine are replaced by private stock vaccine, the form must be faxed to the immunization program, and the provider should keep a copy of the completed form in the office records.
Attention:
Fax Number:
Time period of __/__/____ to ___/___/____
Clinic/Provider Name:
Office Contact Name:
Telephone Number/ fax:
E-mail address:
VFC Number:
Vaccine  Borrowed	Patient Name/Patient Identifier	DOB	Date Borrowed	Reason no private stock vaccine was available (circle one)	Date vaccine returned to VFC stock	
				1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)		
				1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)		
				1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)		
				1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)		
				1.Private stock order shipment  delayed
2.Private stock order non-viable on arrival
3. other (specify)		
"I hereby certify, subject to penalty under the False Claims Act (31 U.S.C. § 3730) and other applicable Federal and state law, that VFC vaccine dose borrowing and replacement reported on this form has been accurately reported and conducted in conformance with VFC provisions for such borrowing  and further certify that all VFC doses borrowed during the noted time period have been fully reported on this form."
Provider Name:	____________________________Provider Signature: _________________________________________Date: ____________  

http://www.cdc.gov/vaccines/programs/vfc/downloads/vfc-op-guide/07-module-3.rtf