General Forms

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

• Materials Request 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:

• Adult Vaccine Administration Record (DHHS 4057)
• Adult Vaccination Record (DHHS 4040)
• Frozen Vaccine Temperature Storage Log
• Lifetime Immunization Record
• Minimum Vaccine Ordering, Handling and Storage Procedures
• Refrigerated Vaccines Temperature Storage Log
• Storage and Handling Vaccine Guide
• UCVDP Vaccine Disaster Recovery Plan
• UCVDP Financial Restitution Policy (12/07)
• Vaccine Administration Record (DHHS 4041)
• Vaccine Administration Log (VAL 120)
• Vaccine Requisition Inventory Form (DHHS 1227)
• Vaccine Transfer Form
• Wasted/Expired Vaccine Report (DHHS 3974)