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. Immunization Record & History Form (.pdf)
4. Patient Eligibility Screening Record Form (.pdf)
   Patient Eligibility Screening Record form in SPANISH language (.pdf) NEW! July 20, 2004
5. Provider Enrollment Form (.pdf) Last updated April 5, 2004
6. Provider Profile Form (.pdf)
7. Provider Profile Supplemental Form (.pdf)
8. Quality Assurance Review (QAR) (.doc)
9. Vaccine Order Form (.pdf) UPDATED August 3, 2004
10. Vaccine Return or Transfer Report Form (.pdf)
11. Vaccine Usage Log Form (.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.

	.doc format	Power Outage Report (from Arizona VFC)
		Refrigerators/Freezers Storing Vaccines Incident Report of Power Outage/Failure
		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)

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. Immunization Record & History Form (text-only for screen-reader devices)
4. Patient Eligibility Screening Record Form (text-only for screen-reader devices)
   Patient Eligibility Screening Record form in SPANISH language (text-only for screen-reader) NEW! July 20, 2004
5. Provider Enrollment Form (text-only for screen-reader devices)
6. Provider Profile Form (text-only for screen-reader devices)
7. Provider Profile Supplemental Form (text-only for screen-reader devices)
8. Quality Assurance Review (QAR) (text-only for screen-reader devices)
9. Vaccine Order Form (text-only for screen-reader devices) UPDATED 8-3-04
10. Vaccine Return or Transfer Report Form (text-only for screen-reader devices)
11. Vaccine Usage Log Form (text-only for screen-reader devices)

• 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 August 13, 2004