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VFC & 317 Vaccine Off-Site Clinic Request Form
Name of provider:
*
PIN:
*
Address of off-site clinic location:
*
Date of off-site clinic:
*
+
Name of staff responsible for the vaccines during the off-site clinic:
*
Has this person taken the current year VFC Training Course?
*
Yes
No
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.
Email of responsible staff:
(this address will receive a copy of this completed form)
*
Direct phone number of responsible staff:
*
Length of off-site clinic (including transport time):
Note: Clinics lasting more than 8 hours, including transport time, are prohibited unless you are storing the vaccine on-site in a pharmaceutical-grade refrigerator or freezer.
*
1 Hour
2 Hours
3 Hours
4 Hours
5 Hours
6 Hours
7 Hours
8 hours
Will the total off-site clinic time (including transport time) be less than 8 hours?
*
Yes
No
Will this be a recurring clinic?
*
Yes
No
If yes, how frequently will it occur?
Vaccine Funding Source:
*
VFC
317
Will you be screening for VFC/317 eligibility at this clinic?
*
Yes
No
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?
Vaccine
Lot Number
Expiration
1
Vaccine
Lot Number
Expiration
2
Vaccine
Lot Number
Expiration
3
Vaccine
Lot Number
Expiration
4
Vaccine
Lot Number
Expiration
5
Vaccine
Lot Number
Expiration
6
Vaccine
Lot Number
Expiration
7
Vaccine
Lot Number
Expiration
8
Vaccine
Lot Number
Expiration
9
Vaccine
Lot Number
Expiration
10
Vaccine
Lot Number
Expiration
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
.
*
Portable Vaccine Storage Unit
Qualified container and pack out (Vericor, Acutemp, etc.)
Styrofoam Container (NOT RECOMMENDED BY CDC FOR OFF-SITE CLINICS)
Hard-Sided Food Cooler (NOT RECOMMENDED BY CDC FOR OFF-SITE CLINICS)
Other
Other
What type of insulating materials will you be using?
*NO ICE OR GEL PACKS PERMITTED
*
None, using portable fridge/freezer
Insulated Panels
Conditioned water bottles
Other
Other
Brand Name and Model Number
*
How many transport units will be used for this off-site clinic?
*
Do you have a sufficient amount of data loggers for each storage container?
*
Yes
No
Upload data logger calibration certificates for all transport units to be used at this off-site clinic:
*
Additional data logger calibration certificate or packing list (optional):
Additional data logger calibration certificate or packing list (optional):
Additional data logger calibration certificate or packing list (optional):
Additional data logger calibration certificate or packing list (optional):
Additional Comments for the VFC Program:
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.
Check the boxes to attest that all information is accurate
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.
Check the boxes to attest that all information is accurate
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.
Check the boxes to attest that all information is accurate
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.
Check the boxes to attest that all information is accurate
I attest I have read and agree to comply with all requirements described within the VFC & 317 Off-Site Clinic Policy.
Check the boxes to attest that all information is accurate
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.
Check the boxes to attest that all information is accurate
The VFC Program will respond to your request within one business day.
Thank you.