Colorado VFC & 317 Vaccine Off-Site Clinic Request Form

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Will this be a recurring clinic? *
Has this person taken the 2019 CDC You Call the Shots trainings? (Vaccines for Children Module 16 and Storage & Handling Module 10) *
If no, this person must take the 2019 VFC and Storage and Handling trainings and submit certificates to VFC prior to the off-site 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 contact the VFC Program at 303-692-2650 or cdphe_vfc@state.co.us
Have any of the vaccines you intend to administer been involved in a temperature excursion? (Please verify by looking over excursion documents and lot numbers.) *
Was this excursion reported to the VFC Program?
What type of storage unit will you be using? *
 
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? *
The VFC Program will respond to your request within one business day.
Thank you.