2018 Colorado Vaccines for Children (VFC) Provider Interest Form

The online form cannot be saved. Please be prepared to upload your backup thermometer calibration certificates.
 
REQUIRED: Your clinic must participate in the Colorado Immunization Information System (CIIS) in order to be a VFC provider. To obtain a CIIS Clinic ID you must register your individual clinic or medical group in CIIS. Enroll your individual clinic or medical group in the CIIS Resource Center under the appropriate entity type. Please complete this step prior to completing the Provider Interest Form.
 
Please have your CIIS Clinic Code and Administrator Name available.
 
Please contact the VFC Program at cdphe_vfc@state.co.us or at 303-692-2650 if you have questions or need additional information. 
 
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 completed provider interest form. A VFC staff member will contact you directly.
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TYPE OF ENROLLMENT REQUEST

Has this clinic been enrolled in the VFC Program before? *
 

FACILITY INFORMATION

CLINIC INFORMATION

Clinic Information *
Please answer
YesNo
Is this clinic open and and seeing patients at the time of filling out this form?
Do all MDs, DOs, NPs, and PAs have Medicaid Numbers?
Does this clinic have privately purchased vaccines in stock?
Is this clinic monitoring and recording twice daily temperatures in all vaccine storage units?
Does this clinic have a computer and internet access readily available to all staff?
Does this clinic currently participate in the Colorado Immunization Information System (CIIS)?
 *
 
 *
 

VACCINE STORAGE UNIT(S) INFORMATION

PLEASE INDICATE THE BRAND AND MODEL OF VACCINE STORAGE UNITS USED AT YOUR OFFICE. DEFINITIONS OF EACH GRADE ARE INCLUDED BELOW. PLEASE NOTE:  PROVIDERS ARE REQUIRED TO HAVE PHARMACEUTICAL GRADE STORAGE UNITS FOR REFRIGERATED VACCINES.
Appropriate Refrigerator Storage Units for VFC Vaccine
 
Pharmaceutical: Also called “purpose-built,” these units are REQUIRED for refrigerated vaccine storage at any time:  These units are designed by the manufacturer specifically to store vaccines. Stand alone or combination units are acceptable.
 
Appropriate Freezer Storage Units for VFC Vaccine
 
Pharmaceutical: Also called “purpose-built," these units are designed by the manufacturer specifically to store vaccines or other biological materials. (PREFERRED) Stand alone or combination units are acceptable.
 
Commercial: Although usually intended to store food and beverages, commercial units are often larger and more powerful than the household units found in most homes. Although these units are intended to meet the higher demands of larger facilities, these units are not specifically built for the storage of biological materials. *These units are PROHIBITED for refrigerated vaccine storage but may be used for frozen vaccine storage. Stand alone units are acceptable.
 
Household (non-commercial/domestic): These units are usually smaller than commercial units and are intended for use in small offices and in homes – typically for food storage. However, just like commercial units, they are not designed specifically for the storage of biological materials. Such units are usually available in common home supply stores. *These units are PROHIBITED for refrigerated vaccine storage but may be used for frozen vaccine storage. Stand alone units are acceptable.
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**Dormitory style (or bar-style) units are PROHIBITED for ANY vaccine storage at any time: a small combination refrigerator/freezer unit that has one exterior door and an evaporator plate (cooling coil), which is located inside an icemaker compartment (freezer) within the refrigerator. 

INDICATE INFORMATION FOR YOUR PRIMARY REFRIGERATOR STORAGE UNIT BELOW:

IS THIS UNIT USED TO STORE PRIVATE VACCINE? *
WILL THIS UNIT BE USED TO STORE VFC VACCINE? *
Use *
Refrigerator Type *
 
Refrigerator Grade *

INDICATE INFORMATION FOR YOUR PRIMARY VFC FREEZER STORAGE UNIT BELOW:

IS THIS UNIT USED TO STORE PRIVATE VACCINE? *
WILL THIS UNIT BE USED TO STORE VFC VACCINE? *
Use *
Freezer Type *
 
Freezer Grade *

IF YOU HAVE ADDITIONAL VACCINE STORAGE UNITS USED TO STORE VACCINE

INDICATE INFORMATION FOR ADDITIONAL REFRIGERATOR STORAGE UNIT BELOW:
IS THIS UNIT USED TO STORE PRIVATE VACCINE?
WILL THIS UNIT BE USED TO STORE VFC VACCINE?
Use
Refrigerator Type
 
Refrigerator Grade
INDICATE INFORMATION FOR ADDITIONAL FREEZER STORAGE UNIT BELOW:
IS THIS UNIT USED TO STORE PRIVATE VACCINE?
WILL THIS UNIT BE USED TO STORE VFC VACCINE?
Use
Freezer Type
 
Freezer Grade

DATA LOGGER TEMPERATURE MONITORING EQUIPMENT INFORMATION

The Colorado VFC Program will supply the VFC400 digital data logger required for use as the primary thermometer to monitor temperatures in your primary refrigerator and freezer used to store VFC vaccines. Please report the backup data logger thermometer information below.
 
NEW: 01-01-2018 Requirement: VFC providers will be required to use data loggers as backup thermometers. The TRED30-16R, TRED30-7R, and VFC400 model data loggers will meet the 2018 CDC requirement. The backup data logger must be dual calibrated or be calibrated specifically for the unit it will monitor.
 
Single Point Calibration is when the logger or thermometer is tested at one standard temperature.  For example, a logger passing calibration testing at 5°C can be used in a refrigerator.  
 
Two Point Calibration or Dual Calibration is when the logger or thermometer is tested at two standard temperatures.  For example, a logger passing calibration testing at 5°C and -15°C can be used in either the refrigerator or freezer.  
 
Certificates of Calibration must indicate thermometers are calibrated for a period of two years.

BACK UP DATA LOGGER THERMOMETERS

PROVIDE YOUR REFRIGERATOR BACK UP DATA LOGGER THERMOMETER INFORMATION BELOW:
Thermometer Type *
 
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Type of Calibration *
Does your clinic have a Certificate of Calibration for your back up refrigerator's thermometer? *

PROVIDE YOUR FREEZER BACK UP DATA LOGGER THERMOMETER INFORMATION BELOW:
Thermometer Type *
 
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Type of Calibration *
Does your clinic have a Certificate of Calibration for your back up freezer's thermometer? *

Please contact the VFC Program at cdphe_vfc@state.co.us or at 303-692-2650 if you have questions or need additional information.