Provider Forms

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

Local Public Health Agency

• Adult – Order and Accountability (Fillable)
• Adult – Tally Sheet

Universal Forms

• Accountability Form (Fillable)
• Borrowing Form
• Disenrollment
• Eligibility record
• Emergency Response Plan
• Immunization Consent and History Form
• Influenza Vaccine Order and Accountability Form
• Order Form (Fillable)
• Provider Update
• Tally Sheet
• Temperature Log - Fahrenheit or Celsius
• Vaccine Freezer Setup
• Vaccine Information
• Vaccine Management Plan
• Vaccine Refrigerator Setup
• Vaccine Replacement
• Vaccine Transfer Report
• Vaccine Wastage and Return Packing Slip
• VAERS Form