Vaccines for Children (VFC) Change of Information Form

Instructions: Providers are required to notify the VFC Program if there are changes in:

Key VFC staff - Add all new & existing contacts. Contacts not listed on this form will be removed from the account.
Days or hours of operation
Shipping or mailing address
Staff contact information including email addresses, phone or fax numbers.

This online form cannot be saved. Be prepared to UPLOAD the VFC annual training certificates before starting this form.

Please see the 2024 Vaccines for Children Annual Training Guidance to complete the training and download a pdf certificate. Do not email them to the VFC Program.

Training certificates required for:

NEW Primary Vaccine Coordinator
NEW Secondary Vaccine Coordinator
NEW Provider of Record (MD, DO, PA, NP)

Hit the SUBMIT button at the end of this form. After submitting the form, an email confirmation will be sent. Keep a copy of the VFC Change of Information form for your records.

VFC Program Contact information: 303-692-2650 or cdphe_VFC@state.co.us

VFC PIN *

Facility Name *

Facility Shipping Address (location where vaccines are shipped to) *

City *

State *

County *

Zip Code *

Telephone Number *

Fax Number *

The standard delivery schedule for VFC and 317 vaccines will be Tuesday, Wednesday and Thursday between 8:00 am and 5:00 pm.

Please indicate the clinic hours including lunch closures on Tuesday, Wednesday and Thursday. *

	Start time	End time	Start time	End time
Tuesday	Start time	End time	Start time	End time
Wednesday	Start time	End time	Start time	End time
Thursday	Start time	End time	Start time	End time

Special Delivery Instructions (e.g. deliver to pharmacy, etc.)

Designated Vaccine Contacts

NEW Provider of Record, Primary Vaccine Coordinator, and Secondary Vaccine Coordinator must complete the 2024 Vaccines for Children (VFC) Annual training in COTrain.

PDF Training certificates must be uploaded for each NEW contact in this form.

DEFINITION OF TYPES OF CONTACTS:
*Provider of Record - this is the medical director (or equivalent) at the office who must sign enrollment forms and ensure compliance with VFC Program requirements.
*Primary Vaccine Coordinator - the staff person who will be responsible for the day to day management of vaccines at the clinic including inventory reconciliation and ordering, and for ensuring all vaccines are stored and handled correctly. Staff may be Primary or Secondary VFC Vaccine Coordinator at only one location.
*Secondary Vaccine Coordinator - all providers must have at least one other staff person fully trained to be responsible when the primary vaccine coordinator is unavailable. Staff may be Primary or Secondary VFC Vaccine Coordinator at only one location.

*Back-up Vaccine Coordinator - additional staff who share responsibility for vaccine management activities and may be on-
site part-time and/or at multiple locations.

*Mailing Contact - this person will receive VFC communications only.

Provider of Record (MD, NP, DO, PA)
First Name *

Provider of Record (MD, NP, DO, PA)
Last Name *

Title *

Provider of Record (MD, NP, DO, PA)
Email Address *

Provider of Record (MD, NP, DO, PA)
Direct Telephone Number *

Is this person a new Provider of Record (MD, NP, DO, PA) for this site? *

Upload the VFC Annual Training Certificate *

Staff may be a Primary or Secondary Vaccine Coordinator at only one location.

Primary Vaccine Coordinator
First Name *

Primary Vaccine Coordinator
Last Name *

Primary Vaccine Coordinator
Email Address *

Primary Vaccine Coordinator
Direct Telephone Number *

Is this person a new Primary Vaccine Coordinator for this site? *

Upload the VFC Annual Training Certificate *

Is this person permitted to order vaccine through CIIS for this site? *

What is the CIIS username for this person?
(A CIIS username is required to order VFC vaccine. If they don't have a CIIS username yet, please leave this section blank)

Did this person take the vaccine inventory reconciliation and ordering training? *

Secondary Vaccine Coordinator
First Name *

Secondary Vaccine Coordinator
Last Name *

Secondary Vaccine Coordinator
Email Address *

Secondary Vaccine Coordinator
Direct Telephone Number *

Is this person a new Secondary Vaccine Coordinator for this site? *

Upload the VFC Annual Training Certificate *

Is this person permitted to order VFC vaccine through CIIS for this site? *

What is the CIIS username for this person?
(A CIIS username is required to order VFC vaccine. If they don't have a CIIS username yet, please leave this section blank)

Did this person take the vaccine inventory reconcilation and ordering training? *

Please add any new or existing contacts who, in addition to the Primary and Secondary vaccine coordinators above, need access to vaccine ordering or need to receive VFC communications. Existing contacts not listed on this form will be removed from the account.

Back-up Vaccine Coordinator
First Name

Back-up Vaccine Coordinator
Last Name

Back-Up Vaccine Coordinator
Email Address

Back-up Vaccine Coordinator
Direct Telephone Number

Is this person a new Back-up Vaccine Coordinator for this site?

OPTIONAL: Upload the VFC Annual Training Certificate

Is this person permitted to order VFC vaccine through CIIS for this site?

What is the CIIS username for this person?
(A CIIS username is required to order VFC vaccine. If they don't have a CIIS username yet, please leave this section blank)

Did this person take the vaccine inventory reconcilation and ordering training?

Back-up Vaccine Coordinator
First Name

Back-up Vaccine Coordinator
Last Name

Back-Up Vaccine Coordinator
Email Address

Back-up Vaccine Coordinator
Direct Telephone Number

Is this person a new Back-up Vaccine Coordinator for this site?

OPTIONAL: Upload the VFC Annual Training Certificate

Is this person permitted to order VFC vaccine through CIIS for this site?

What is the CIIS username for this person?
(A CIIS username is required to order VFC vaccine. If they don't have a CIIS username yet, please leave this section blank)

Did this person take the vaccine inventory reconcilation and ordering training?

Back-up Vaccine Coordinator
First Name

Back-up Vaccine Coordinator
Last Name

Back-Up Vaccine Coordinator
Email Address

Back-up Vaccine Coordinator
Direct Telephone Number

Is this person a new Back-up Vaccine Coordinator for this site?

OPTIONAL: Upload the VFC Annual Training Certificate

Is this person permitted to order VFC vaccine through CIIS for this site?

What is the CIIS username for this person?
(A CIIS username is required to order VFC vaccine. If they don't have a CIIS username yet, please leave this section blank)

Did this person take the vaccine inventory reconcilation and ordering training?

Mailing Contact
First Name

Mailing Contact
Last Name

Mailing Contact
Email Address

Mailing Contact
Direct Telephone Number

Mailing Contact
First Name

Mailing Contact
Last Name

Mailing Contact
Email Address

Mailing Contact
Direct Telephone Number

Please provide any additional information as needed (i.e. reason for submitting form, date clinic moving, etc):

0/300 characters

Please enter your email address to receive a copy of the completed form. Then hit the SUBMIT button below. *