H1N1 Vaccine Order Form

This page includes the H1N1 Vaccine Order Form for North Carolina. Only vaccine providers with a valid H1N1 provider agreement with the NC Immunization Branch may order H1N1 vaccine via this website.

Instructions:

Click on the link in the box below and enter information in all the fields to place your order.

Each presentation of vaccine must be ordered in quantities of 100 doses.

Orders are due by 5 p.m. on Tuesdays for delivery the following week.

Vaccine orders will be fulfilled as best we can based on supplies allocated weekly by CDC. Replacement vaccine of other presentations will not be ordered to fulfill your total doses ordered.

If you have questions, or need help with this form, call the Immunization Branch at 1-877-873-6247. You may also refer to the memo from the Immunization Branch dated December 30, 2009.

H1N1 Vaccine Order Form

 

Doses Administered:

Please remember to submit a doses administered report each week via the Weekly Aggregate H1N1 Influenza Vaccine Use Form. Completed forms must be faxed to the Branch at 1-800-544-3058 or e-mailed to H1N1doses@dhhs.nc.gov by 12 PM (noon) every Monday even if there has been no usage of H1N1 vaccine in the past week. Do not use hash or tic marks. If no doses have been administered put a check in the appropriate field.

• 2009 H1N1 Aggregate Report (PDF Format)
• 2009 H1N1 Aggregate Report (Modifiable Word Format)