Providers should maintain all records related to the VFC program for a minimum of three years, and make these records available to public health officials, including the state or Department of Health and Human Services, (DHHS) upon request.  These records include (but are not limited to) patient screening forms, temperature logs, and any other reports or documents from the VFC Program. 

General Forms

All forms are Adobe Acrobat PDF () unless otherwise noted.

• Materials Request Form
• Medical Exemption Statement (DHHS 3987)
• Physicians Request for Medical Exemption (DHHS 3995)
• Vaccine Injury Compensation Program (VICP) Adverse Reaction Reporting System Questions & Answers
• VAERS Reporting Form for Providers

Vaccine-Related Forms

All forms are Adobe Acrobat PDF () unless otherwise noted.

General Vaccine Forms:

• Vaccine Requisition Inventory Order Form (DHHS 1227)
• Vaccines Administered Log
• Vaccine Administration Record
• Adult Vaccine Administration Record
• Borrowing and Replacement from NCIP Vaccine Supplies
• Frozen Vaccine Temperature Storage Log
• Refrigerated Vaccines Temperature Storage Log
• Lifetime Immunization Record
• Minimum Vaccine Ordering, Handling and Storage Procedures (Post in clinic)
• Vaccine Storage and Handling Toolkit (links to CDC website)
• Disaster Recovery Plan
• Financial Restitution Policy (12/07)
• Vaccine Transfer Form
• Wasted/Expired Vaccine Report (DHHS 3974)