Provider Forms

Please remember to put your VFC PIN Number on each form.

Local Public Health Agency

• Order Form
• Accountability
• Tally Sheet
• Adult – Order and Accountability
• Adult – Tally Sheet
• Adult Hepatitis Initiative – Order and Usage Report
• Adult Hepatitis Initiative – Tally Sheet
• Transfer and Replacement Report
• Flu – Flu Order Form
• Flu – Flu Tally Sheet

Private Provider

• Order Form
• Accountability
• Tally Sheet
• Transfer and Replacement Report
• Flu – Flu Order Form
• Flu – Flu Tally Sheet

Universal Forms

• 317 FAQ
• Borrowing Form
• Disenrollment
• Eligibility record
• Fax Back
• Immunization Consent and History Form
• Temperature Log - Fahrenheit or Celsius
• Vaccine Return Slip
• Vaccine Management Plan
• Vaccine Information
• Vaccine Freezer Setup
• Vaccine Refrigerator Setup
• Emergency Response Plan