VFC Forms

Forms Found in VFC Operations Guide

• Patient Eligibility Screening Record [286 KB, 6 pages] (page 1 of Appendix 3)
  VFC eligibility screening must take place with each immunization visit to ensure the child’s eligibility status has not changed. This same record will satisfy the requirements for all subsequent vaccinations, as long as the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine.

• Patient Eligibility Screening Record - Vaccines for Children Program in Family Planning Clinics [286 KB, 6 pages] (page 4 of Appendix 3)
  VFC eligibility screening must take place with each immunization visit to ensure the child’s eligibility status has not changed. This same record will satisfy the requirements for all subsequent vaccinations, as long as the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine.

• Comprehensive Certification Form for American Indians and Alaska Natives [286 KB, 6 pages] (page 2 of Appendix 3)
  This form may be substituted for individual VFC screening records when 100% of the persons to be immunized at this facility are American Indians or Alaska Natives. Retain a copy of this form at your facility and send the original to the State Health Department or state public health agency of record. Provider enrollment and Provider Profile forms for this practice must be on file with the State Health Department or public health agency of record. Certification must be re-issued annually when provider profile is submitted.

• Comprehensive Certification Form for Children Who Are Enrolled in Medicaid [286 KB, 6 pages] (page 3 of Appendix 3)
  This form may be substituted for individual VFC screening records when 100% of the persons to be immunized at this facility are Medicaid enrolled. Retain a copy of this form at your facility and send the original to the State Health Department or state public health agency of record. Provider enrollment and Provider Profile forms for this practice must be on file with the State Health Department or public health agency of record. Certification must be re-issued annually when provider profile is submitted.

• Family Planning Clinic - Unaccompanied Minor without Insurance Information VFC Vaccine Log [286 KB, 6 pages] (page 5 of Appendix 3)
  This log must be completed and submitted to the state immunization program on a monthly basis. To prevent duplication of patient count, please record all vaccines administered to one patient on a single line. This report is in addition to other VFC reports required by the state immunization program. In completing this log, document only the administration of any VFC vaccine to unaccompanied minors (through 18 years of age) who present without insurance information. Please keep one copy for your clinic's records and send one to the State Immunization Program at the address on the log/form.

• Border State Memorandum of Understanding (MOU) – VFC [286 KB, 6 pages] (page 6 of Appendix 3)
  This sample agreement offers wording for MOUs to serve children who are eligible for VFC vaccinations, who reside in one state but are served by private health care providers in a neighboring state.

• Protocol for Assessing VFC Eligibility Screening, Definitions of Site Visits form [24 KB, 1 page] (from Appendix 6)

• Provider Profile [156 KB, 1 page] (from Appendix 2)
  All state- or awardee-approved public and private health care providers participating in the Vaccines for Children (VFC) program must complete this form. This document provides shipping information and helps the state determine the amount of vaccine to be supplied through the VFC program. This form may also be used to compare estimated vaccine needs with actual vaccine supply. The state health department must keep this record on file with the “Provider Enrollment” form. The Provider Profile form must be updated annually or more frequently if 1) the number of children being served changes, or 2) the status of the facility changes. One provider may complete the form for the entire practice.

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