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Provider Portal: FORMS AND REPORTS

VFC/WyVIP Specific Forms


Single Eligibility Screening Form                                          (7/01/14)


Patient Eligibility Screening Record  


Vaccine Administration Form 
Now available for providers to print and use


VUA/AHV Specific Forms 


Eligibility Screening Form  NEW!


Temperature Recordings

Temperature Log - REFRIGERATOR        

Temperature Log-FREEZER                    

Hourly Temperature Log for Off-Site Clinics   

Temperature Excursions

Vaccine Cold Chain Incident Report 

Vaccine Inventory

Vaccine Return Form NEW!

Order Volume Justification Form   

Facility Relocation Notification 

Borrowed Vaccine Report                      NEW

*The Short-Dated Vaccine Transfer Request Form has been replaced with Vaccine Advertisement. See Quick Reference Guide.

Administrative Forms

Provider Profile 2016

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

1/1/16        New Year's Day

1/18/16      Equality Day

2/18/16      President's Day

5/30/16      Memorial Day

7/4/16        Independence Day

9/5/16        Labor Day

11/11/16    Veteran’s Day

11/24/16    Thanksgiving

12/25/16    Christmas