COVID-19 Vaccine Off-Site Clinic Request Form

Submit this form to request approval from the COVID-19 Program to transport COVID-19 vaccines prior to scheduling off-site clinics.
All off-site clinics require PRIOR approval from the COVID-19 Program. Please allow two business days for processing.
Has this person taken the required CDC Storage and Handling Training?

Will the total off-site clinic time (including transport time) be less than 8 hours?
Will this be a recurring off-site clinic at the same location? *
Do you have the COVID-19 Vaccination Off-Site Clinic Checklist printed for the off-site clinic? *
Which presentations of COVID-19 vaccines will you be administering?
Please note: all vaccine administrations must be submitted into the Colorado Immunization Information System (CIIS) either electronically or manually within 72 hours and include the required components:
• the name of vaccine
• the date it was given
• the route and administration site
• the lot number and manufacturer
• the name and title of the person who administered it
• the clinic’s name and address
• the VIS/EUA publication date and date VIS/EUA was provided
 Vaccine PresentationLot NumberExpiration DateBeyond-Use Date (if applicable)How many doses will be transported to the off-site clinic
If you are administering more than ten vaccines, please contact the COVID-19 Program at
What type of transport unit will you be using?
*Please see list of approved portable units.
What type of insulating materials will you be using?

Attestation Agreement *
 Check the boxes to attest that all information is accurate
I attest that any recurring off-site clinic that is approved will be held at the same location, with the same information included on the original request.
I acknowledge that recurring off-site clinics held at the same location will only need approval once, and approval is contingent upon all requirements being met.
I attest to having a current certificate of calibration for all digital data loggers that will be used during approved recurring and one time COVID-19 off-site clinics.
I understand that all approved COVID-19 off-site clinics require the COVID-19 Off-Site Clinic Checklist to be completed, in its entirety within 2 business days of the off-site clinic being held.
I attest I have read and agree to comply with all requirements described within the COVID-19 Off Site Clinic Policy.
I attest all information in this document is accurate and any out of range temperatures will be immediately reported to the COVID-19 Vaccination Program at
The COVID-19 Vaccine Program will respond to your request within two business days. Thank you.