VFC Forms and Records

Patient Eligibility

• Patient Eligibility Screening Record, Vaccines for Children Program
• Comprehensive Certification Form for American Indians and Alaskan Natives
• Comprehensive Certification Form for Children Enrolled in Medicaid
• Patient Eligibility Screening Record for Family Planning Clinics
• Unaccompanied Minor without Insurance Information VFC Vaccine Log

Provider Enrollment Forms

• Initial Enrollment Forms
• Reenrollment Forms
• Disenrollment Form
• Maximum Regional Charges for Vaccine Administration
• Suspected Fraud and Abuse Report Form

Vaccine Reporting Forms

• List of Ordering Schedules by PIN
• Vaccine Report Forms and Ordering Schedules
  Providers will now report and order through the Florida SHOTS™ system. Please login.
• Vaccine Report Form Additional Page
• Vaccine Administration Redistribution Agreement

Other Order Forms

• Varicella-Containing Vaccine Order Form
  Providers will now order through the Florida SHOTS™ system. Please login.

Vaccine Management

• Temperature Log for Vaccines (Fahrenheit)
• Temperature Log for Vaccines (Celsius)
• Vaccine Usage Worksheet
• Vaccine Return and Waste Form
  Providers will now report and order through the Florida SHOTS™ system. Please login.
• Vaccine Transfer Form
  Providers will now report and order through the Florida SHOTS™ system. Please login.
• Cooler Temperature Log
• Vaccine Management Plan
• Using a Data Logger to Ensure Proper Vaccine Management
• Emergency Response Plan

*Note: This page contains materials in the Portable Document Format (PDF). The free Acrobat Reader may be required to view these files.