VFC/WYVIP PROGRAM:  FORMS AND REPORTS

 

CONTACTS

Reporting Requirements Table                           (4/10/13)

 

*How to Submit a PDF Form                                (1/06/14) 


 

PROVIDER REPORTS

Sample Eligibility Screening Form                      (July 2013)

 

Temperature Log-Refrigerator                          (12/24/13)

 

Temperature Log-Freezer                                  (12/24/13)

 

Vaccine Return Form*                                        (1/01/14)

 

Short-Dated Vaccine Transfer Request*              (1/01/14)     

       

Borrowed Vaccine Report                                    (1/01/14)  

 


 

SPECIAL FORMS

 

Vaccine Cold Chain Incident Report           NEW     (2/14/14)   

 

Vaccine Order Justification Form for Special Clinics  (4/10/13)

 

Hourly Temperature Log for Off-site Clinics           (01/06/14)   

 

Current Inventory Form                                         (4/10/13)

 

Doses Administered Form                                       (4/10/13)

 

Vaccine Request Form                                            (4/10/13) 


 

ADMINISTRATIVE FORMS

 

 Provider Profile*                                                       (1/01/14)

 

Vaccine Coordinator Checklist*                                 (1/02/14)

Provider Withdrawal Form                                      (1/07/13)  

Moving Notification Form                                NEW (2/05/14)

 

Material Request Form                                             (6/05/13) 

 

 

 


Jude Alden, MBA
Vaccine Program Specialist
307-777-2413
jude.alden@wyo.gov

 

LaChel May
Provider Relations Administrative Assistant
307-777-8503 or
307-777-7952
lachel.may@wyo.gov

Fax: 307-777-3615

 

2014 STATE HOLIDAYS

1/1/14 -   New Year’s Day

1/20/14 - Equality Day

2/17/14 - President’s Day

5/26/14 -  Memorial Day

7/4/14 -    Independence  Day

9/1/14 -    Labor Day

11/11/14 - Veteran’s Day

11/27/14 - Thanksgiving

12/25/14 -  Christmas