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Provider Portal: FORMS AND REPORTS

Sample Eligibility Screening Form                                          (7/01/14)


Temperature Recordings

Temperature Log - REFRIGERATOR        NEW 

Temperature Log-FREEZER                    NEW   

Hourly Temperature Log for Off-Site Clinics   

Temperature Excursions

Vaccine Cold Chain Incident Report 

Vaccine Inventory

Vaccine Return Form

Short-Dated Vaccine Transfer Request    NEW 

Order Volume Justification Form   

Facility Relocation Notification 

Borrowed Vaccine Report                      NEW

Administrative Forms

Provider Profile 

Vaccine Coordinator Checklist  







Jude Alden, MBA, CPM
VFC Coordinator

Lisa Sara
Provider Support Specialist


              Quick Links

Provider Portal

Enrollment and Withdrawal

Educational Resources

Regional Training


Click here to update your facility contacts


      State Holidays

1/1/15        New Year's Day

1/19/15      Equality Day

2/16/15      President's Day

5/25/15      Memorial Day

7/4/15        Independence Day

9/7/15        Labor Day

11/11/15    Veteran’s Day

11/26/15    Thanksgiving

12/25/15    Christmas