Forms
General Vaccine
CQIIP Tool PDF 15 May 12
The MILVAX Continuous Quality Immunization Improvement Process (CQIIP) tool will provide immunization personnel with a quality control tool to assess the immunization process and ensure compliance with the eight Standards for Military Immunizations as outlined in the Department of Defense (DoD) Joint Instruction and the Centers for Disease Control and Prevention (CDC) Immunization Recommendations
CQIIP Instructions PDF 15 May 12
MILVAX Instruction Guide for completing the Continuous Quality Immunization Improvement Process (CQIIP) Tool
Emergency Vaccine Retrieval and Storage Plan Worksheet PDF 08 May 12
Military Vaccine Agency
Potential Compromised Vaccine Worksheet PDF 24 Apr 12
Published by the MILVAX Agency
Temperature Log for Vaccines (Celsius) 2x Daily Checks PDF 23 Apr 12
Military Vaccine Agency
Temperature Log for Vaccines (Fahrenheit) 2x Daily Checks PDF 23 Apr 12
Military Vaccine Agency
Immunization Requirments Form 16 Nov 11
Department of Defense Education Activity
Monthly Care of Vaccine Storage Units Checklist PDF 03 Feb 11
Military Vaccine Agency
Temperature Log for Vaccines (Celsius) 4x Daily Checks (Army) PDF 27 Oct 10
Military Vaccine Agency
Emergency Vaccine Retrieval and Storage Plan Worksheet PDF 29 Mar 10
Military Vaccine Agency
VAERS 09 Jan 06
Vaccine Adverse Event Reporting System
Initial Competency Assessment - Allergy / Immunizations & Travel Medicine PDF 07 Nov 05
DiLorenzo TRICARE Health Clinic
Adenovirus
Adenovirus Competency Form PDF 26 Jul 11
ADENOVIRUS Type 4 and Type 7 LIVE, ORAL VACCINE, ADMINISTRATION COMPETENCY ASSESSMENT Patient Population Served: Recruits (17-50 yrs)
Anthrax
Anthrax Vaccine in Pregnancy Referral Form PDF 19 Jul 12
Supplemental Form for Anthrax Vaccine in Pregnancy Registry
VAERS 09 Jan 06
Vaccine Adverse Event Reporting System
Next Dose Scheduled Card PDF 26 May 05
Anthrax Vaccine
Army MEDCOM Regulations and AVA Immunization Record (Form 700-R) PDF 04 Sep 03
MEDCOM form #700-R has been rescinded and is no longer to be used for recording anthrax vaccinations.
Please continue to record all vaccinations in the following places:
- Health Record Immunization Record - SF 601
- International Certification of Vaccination - PHS Form 731
- Adult Preventive and Chronic Care Flow-sheet - DD Form 2766 & DD Form 2766C
- Service automated immunization tracking system - MEDPROS/AFCITA/SAMS
Influenza - Seasonal
Standing Order for the Administration of the Influenza Vaccine to Children and Adolescents 2012-13 PDF 11 Sep 12
Military Vaccine Agency
Standing Order for the Administration of the Influenza Vaccine to Adults 2012-13 PDF 12 Jul 12
Military Vaccine Agency
Recommended 2012-13 Influenza Vaccine Screening Questions - Adult PDF 12 Jul 12
Military Vaccine Agency
Recommended 2012-13 Influenza Vaccine Screening Questions - Pediatric and Adolescent PDF 12 Jul 12
Military Vaccine Agency
Influenza Competency Form: INJECTABLE VACCINE PDF 10 Jul 12
2012-13 Seasonal Influenza Vaccination Program
Influenza Competency Form: INTRANASAL VACCINE PDF 10 Jul 12
2012-13 Seasonal Influenza Vaccination Program
Influenza Vaccination Documentation Wallet Card 2012-13 DOCX 05 Jul 12
Military Vaccine Agency
Smallpox
VAERS Smallpox Pregnancy Supplement PDF 19 Jul 12
Supplemental Form for Smallpox Vaccine in Pregnancy Registry
Smallpox Vaccine Screening Form PDF 08 Jan 10
2-page format, STANDARD FORMAT
Smallpox Vaccine Take Check Medical Note PDF 23 Jul 09
Follow-Up Note for Standard "Take-Check" Visits
Smallpox Vaccine Sick Call Medical Note PDF 23 Jul 09
Follow-Up Note for Sick Call Evaluation of Patients [pre position this form at ERs and troop medical clinics]
Initial Competency Assessment: Smallpox Vaccine Administration PDF 07 Mar 08
MILVAX Agency
Initial Competency Assessment: Smallpox Vaccine Reconstitution PDF 07 Mar 08
MILVAX Agency
Smallpox Vaccine Screening or Medical Note Continuation Page PDF 07 Feb 08
Smallpox Vaccination Continuation Note CHRONOLOGICAL RECORD OF MEDICAL CARE
30-day Diary Card PDF 07 Feb 08
Symptom Diary After Smallpox Vaccination
VAERS 09 Jan 06
Vaccine Adverse Event Reporting System
STORAGE & HANDLING
Emergency Vaccine Retrieval and Storage Plan Worksheet PDF 08 May 12
Military Vaccine Agency
Potential Compromised Vaccine Worksheet PDF 24 Apr 12
Published by the MILVAX Agency
Temperature Log for Vaccines (Fahrenheit) 2x Daily Checks PDF 23 Apr 12
Military Vaccine Agency
Temperature Log for Vaccines (Celsius) 2x Daily Checks PDF 23 Apr 12
Military Vaccine Agency
Monthly Care of Vaccine Storage Units Checklist PDF 03 Feb 11
Military Vaccine Agency
Temperature Log for Vaccines (Celsius) 4x Daily Checks (Army) PDF 27 Oct 10
Military Vaccine Agency