Yellow Fever Vaccination Center Application

Complete a separate application for each location.

(Max of 5 yellow fever locations)

*The online form cannot be saved. Please collect all your information and enter the information into this online form.

*Be prepared to ENTER & UPLOAD the following items before starting this form:

1. Enter your medical license number and DEA number (Required for enrollment).

2. Upload the Yellow Fever Vaccine: Information for Health Care Professionals Advising Travelers training certificate for the medical provider (MD, DO, PA, NP) or any staff advising on the provider's behalf.

3. Enter the refrigerator brand, model number, and type.

4. Enter the thermometer brand, serial number, calibration expiration date, and upload the thermometer calibration certificate.

5. Upload a data logger report with five days of temperatures.

6. The signed Yellow Fever Provider Certification and Storage & Handling Agreements.

*Hit the SUBMIT button at the end of this form. After SUBMITTING the Yellow Fever application, an email confirmation will be sent. Keep a copy of the application.

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

Yellow Fever Demographic Information

Date * +

Provider Last Name *

Provider First Name *

Provider MI *

Title *

Provider Direct Phone Number *

Provider Email Address *

CO State Medical License # *

DEA # *

Location where the vaccine will be administered

Please note that the yellow fever vaccine will only be shipped and administered to the address below. The vaccine cannot be redistributed or sent to satellite clinics. If you wish to administer the yellow fever vaccine in other clinics, those clinics must submit a Yellow Fever Program application.

Clinic Name *

Street Address *

Suite # *

City *

Zip Code *

County *

Clinic Phone Number *

Clinic Fax Number *

Clinic Website *

Can the clinic's website be publicly posted on the CDC's Website? *

Yes

No

Type of Clinic (select only one from the drop down menu) *

Is the clinic restricted to members or affiliates only? (such as university students/faculty/staff, company employees, member subscribers) *

Yes

No

Does the clinic administer yellow fever vaccine to those <18 y/o age? *

Yes

No

If the provider’s mailing address is not the same as the clinic address above, enter the provider’s mailing address

Mailing Address

Suite #

City

Zip Code

County

Phone Number

Upload the Yellow Fever training certificate(s)

Yellow Fever training certificate(s) *

Refrigerator Information

Please indicate the brand and model of the vaccine refrigerator that will be used at your clinic for yellow fever vaccine storage.

Providers are required to have pharmaceutical-grade storage units for refrigerated vaccines.

Refrigerator Storage Units for Vaccine

Pharmaceutical-grade units, also called "purpose-built," 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.

Refrigerator Brand: *

Refrigerator Model #: *

Refrigerator Type: *

Stand Alone

Combination

Other Other

Temperature Monitoring Information & Upload Data Logger Report

Yellow Fever Providers are required to use a Digital data logger (DDL) with continuous monitoring capabilities and have a current and valid Certificate of Calibration Testing for each logger, including at least one backup logger.

Certificates of Calibration must indicate that thermometers are calibrated for two years.

*Back-up digital data logger must currently be in calibration (not expired). If your calibration has expired, please recalibrate immediately.

If you do not have digital data loggers that meet CDC minimum requirements, Digital data loggers (DDLs) can be purchased through these companies:

Microdaq Ltd - 603-746-5524
Control Solutions - 503-410-5996
Thermco Products Inc. - 973-300-9100

Please list your current temperature monitoring equipment information below.

Thermometer Brand: *

VFC400 USB

VFC400 WiFi

LogTag TRED30-16R Data logger

Other Other

Thermometer Serial Number: *

Calibration Expiration Date: * +

Upload Thermometer Calibration Certificate: *

Upload 5 days of data logger reports: *

Upload the signed Yellow Fever Provider Certification and Storage & Handling Agreements

Yellow Fever Certification Provider Agreement *

Yellow Fever Storage & Handling Agreement *

Please enter your email address to receive a copy of the submitted application. Then HIT the SUBMIT button below. *