2020 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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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 ages 0-18 years old at the time of submitting this form?
Does your clinic see privately insured patients?
Does your clinic see Medicaid patients?
Does your clinic see CHP+ patients?
Do ALL MDs, DOs, NPs, and PAs have Medicaid Numbers?
Does this clinic have privately purchased vaccines in stock of all ACIP-recommended vaccines for the population you serve?
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)?
Does your clinic have a CIIS interface? (does your immunization data get sent through your EHR to 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. These units should have a microprocessor and fan-forced air. 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. These units should have a microprocessor and fan-forced air.(PREFERRED) Stand alone or combination units are acceptable.
 
Household or commercial grade freezers are acceptable ONLY if they are standalone and not connected to a refrigerator.
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INDICATE INFORMATION FOR YOUR PRIMARY REFRIGERATOR STORAGE UNIT BELOW:

WILL THIS REFRIGERATOR BE USED TO STORE VFC VACCINE? *
IS THIS REFRIGERATOR USED TO STORE PRIVATE VACCINE? *
PLEASE NOTE, IF YOUR REFRIGERATOR STORAGE CAPACITY IS 4-6 CB FT, YOU MAY ONLY STORE VFC OR PRIVATE VACCINE IN THE UNIT, NOT BOTH.
Refrigerator Use *
Refrigerator Type *
 

INDICATE INFORMATION FOR YOUR PRIMARY VFC FREEZER STORAGE UNIT BELOW:

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

IF YOU HAVE ADDITIONAL VACCINE STORAGE UNITS USED TO STORE VACCINE

INDICATE INFORMATION FOR ADDITIONAL REFRIGERATOR STORAGE UNIT BELOW:
WILL THIS REFRIGERATOR BE USED TO STORE VFC VACCINE?
IS THIS REFRIGERATOR USED TO STORE PRIVATE VACCINE?
Refrigerator Use
Refrigerator Type
 
INDICATE INFORMATION FOR ADDITIONAL FREEZER STORAGE UNIT BELOW:
IS THIS FREEZER USED TO STORE PRIVATE VACCINE?
WILL THIS FREEZER BE USED TO STORE VFC VACCINE?
Freezer 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.
 
*Your loggers must currently be in calibration (not expired). If your calibration is expired, please re-calibrate and then submit this form.

BACK UP DATA LOGGER THERMOMETERS

PROVIDE YOUR REFRIGERATOR BACK UP DATA LOGGER THERMOMETER INFORMATION BELOW:
Refrigerator Thermometer Type *
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Refrigerator 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:
Freezer Thermometer Type *
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Freezer 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.