Colorado Vaccine Off-Site Clinic Request Form

Instructions: Providers are required to request approval by the Vaccines for Children (VFC) Program to host off-site clinics.

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

The VFC Program will process the requests for off-site clinic request 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.

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 Off-Site Clinic Request form for your records. 

Please contact the VFC Program at or at 303-692-2650 if you have questions or need additional information. 
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
If you are administering more than ten vaccines, please send them to
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?
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
The VFC Program will respond to your request within one business day.
Thank you.