Vaccines for Children (VFC) Vaccine Transfer Request Form

Instructions: Providers are required to request approval by the Vaccines for Children (VFC) Program to transfer vaccine(s) to another VFC enrolled provider.

*Do NOT move vaccines to another location before getting approval from the VFC Program.

The VFC Program will process the transfer forms received between 8:30 am and 4:30 pm the same day. Forms received after 4:30 pm will be processed the next business day.

When the VFC Program approves the transfer form, VFC staff will create the transfer in the Colorado Immunization Information System (CIIS) for your clinic.

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 Transfer Request form for your records.

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

Transfer Request Information

Date * +

VFC PIN *

Name of Clinic Requesting Vaccine Transfer *

Contact Name *

Contact Direct Telephone Number *

Contact Email *

VFC PIN *

Name of Clinic Receiving Vaccines *

Contact Name of Receiving Clinic *

Contact Direct Telephone Number *

Contact Email of Receiving Clinic *

Date Clinic Plans to Transfer Vaccine(s) * +

Why is the Clinic Requesting to Transfer Vaccine(s)? *

List Vaccine(s) Requesting Transfer
If you are transferring more than 10 vaccines, please contact the VFC program at cdphe_vfc@state.co.us.

	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
1	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
2	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
3	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
4	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
5	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
6	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
7	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
8	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
9	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer
10	Vaccine	Lot Number	Expiration Date/BUD	Fund Source (VFC/317/State)	# of Doses to Transfer

Transport Equipment Information

Please review the types of units allowable to transport vaccines:

List of Allowable Transport Units

Number of transport units to be used for vaccine transfer? *

Portable Unit(s) Brand Name and Model Number *

What type of insulating materials will you be using?
*NO ICE OR GEL PACKS PERMITTED *

Do you have a backup data logger to transport these vaccines?
Note: if clinic is transporting frozen and refrigerated vaccines, two loggers are needed *

Yes

No

Additional Comments for the VFC Program

Attestation Agreement

Attestation Agreement *

I attest that vaccine transfers will occur only upon receipt of approval from the VFC program and is contingent upon all requirements being met.

I attest the vaccines to be transferred have either: 1) not been involved in a storage and handling incident or 2) have been involved in a storage and handling incident, which was reported to and cleared by the Colorado VFC program.

I attest the certificates of calibration for all digital data loggers to be used during approved transfers are current, valid and in my posession.

I attest that I have read and agree to comply with all requirements described within the Vaccine Transfer Request Policy.

I attest that all information in this document is accurate, and that any out of range temperatures occurring during transport will be reported immediately to the VFC Program at cdphe_vfc@state.co.us.

Name of Person Agreeing to Attestation Agreement *

Enter your email address below to receive a copy of this form. *