Health Care Provider Information

 

Forms

Forms

• VAERS Form (pdf) (23K)
  Adverse events following immunization should be reported by public providers to the Immunization Program, Health Services, using a Vaccine Adverse Events Reporting System form (VAERS), according to state guidelines. Private providers report all adverse events directly to VAERS.
  VAERS telephone number is 800-822-2967, and the website address is www.vaers.hhs.org

• Uniform Stamp and Yellow Fever Requests
  
  

Vaccine Administration Record (VAR)

Vaccine Administration Records (VARs) are documents that allow a clinic to capture key information regarding a patients immunization history. These documents are kept in the patients file or electronic medical record. It is public law (99-660) that providers maintain this immunization information in every patients file.

Below is a sample VAR that we have created for your reference and/or use.

These are not to be used for influenza vaccine. The forms for both seasonal and H1N1 influenza can be found in the flu Provider Toolkit.

• Public Clinics - Required VAR

                 English (pdf)                       Spanish (pdf)

• Private Clinics - Sample VAR

                        English (pdf)