Forms

For Private Facilities

• Screening Form
• Vaccine Administration and Screening Form
• Tally Report Form (Benchmarking)
• Monthly Accountability Report Form

For FQHC/RHC/CHC Facilities

• Screening Form
• Vaccine Administration and Screening Form
• Monthly Accountability Report
• FQHC/RHC Vaccine Use Guidelines

For Public Hospitals

• Screening Form
• Vaccine Administration and Screening Form
• Monthly Accountability Report
• Public Hospital Vaccine Use Guidelines

For Local Health Departments

• Local Health Department Quarterly Inventory Report
• Health Department Vaccine Use Guidelines

General

• Vaccine Order Form
• Flu Order Form
• Vaccine Return Form
• New Vaccine Return Process (June 2009)
• Box Change Announcement (June 2009)
• Vaccine Replacement Form
• Temperature Log - Celsius or Fahrenheit
• Storage and Handling Chart
• Medicaid Administration Codes (CPT Codes)

 

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