Colorado Vaccine Off-Site Clinic Request Form

Vaccines for Children (VFC) providers are required to request approval from the VFC program to host off-site clinics with publicly funded vaccines.

*Do NOT conduct an off-site clinic before getting approval from the VFC Program.

The VFC Program will process off-site clinic request forms received between 8:30 am and 4:30 pm the same day. Off-site clinic request forms received after 4:30 pm will be processed the next business day.

INSTRUCTIONS: Hit the SUBMIT button at the end of this form. After submission, a copy of the form will be emailed. Keep a copy of the VFC Off-Site Clinic 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. 
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Is this an off-site school-based vaccination clinic, or a vaccination clinic focused on school-aged children? *
Is this off-site clinic a request or referral from an LPHA? *
 
Has this person taken the current year VFC Training Course? *
If no, this person must take the current year VFC and Storage and Handling trainings and submit certificates to VFC prior to the off-site clinic.
Will the total off-site clinic time (including transport time) be less than 8 hours? *
Will this be a recurring clinic? *
Vaccine Funding Source: *
Will you be screening for VFC/317 eligibility at this clinic? *
Please note: all vaccine administrations must be documented in your EHR and/or CIIS and include the required components per The National Childhood Vaccine Injury Act:
• the name of vaccine
• the date it was given
• the route and administration site
• the lot number and manufacturer
• the name and title of the person who administered it
• the clinic’s name and address
• the VIS publication date and date VIS was provided
 
Which vaccines will you be administering?
 VaccineLot NumberExpiration
1
2
3
4
5
6
7
8
9
10
If you are administering more than ten vaccines, please send them to cdphe_vfc@state.co.us
What type of transport unit will you be using?
*Please see list of approved portable units.
 *
 
What type of insulating materials will you be using?
*NO ICE OR GEL PACKS PERMITTED
 *
 
Do you have a sufficient amount of data loggers for each storage container? *





Attestation Agreement *
 Check the boxes to attest that all information is accurate
I attest that any recurring off-site clinic that is approved will be held at the same location, with the same information included on the original request.
I acknowledge that recurring off-site clinics held at the same location will only need approval once, and approval is contingent upon all requirements being met.
I attest to having a current certificate of calibration for all digital data loggers that will be used during approved recurring and one time VFC & 317 off-site clinics.
I understand that all approved VFC & 317 off-site clinics require the VFC & 317 Off-Site Clinic Checklist to be completed, in its entirety within 2 business days of the off-site clinic being held.
I attest I have read and agree to comply with all requirements described within the VFC & 317 Off-Site Clinic Policy.
I attest all information in this document is accurate and any out of range temperatures will be immediately reported to the VFC Program at cdphe_vfc@state.co.us.
The VFC Program will respond to your request within one business day.
Thank you.