General Forms

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

• Materials Order Form (DHHS 1422)
• 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)
• Vaccine 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)