Download - New VFC Order Form: Why do I have to do this? How do I fill it out? By Laura Harrod, KVP Coordinator
Why do we have to do this form?Part of CDC’s Vaccine Management Business
Improvement Plan or VMBIPCDC is requiring more accountability of
vaccinesNew system called VTrckS or Vaccine
Tracking System requires all information on this form to be able to order any vaccines
This information will need to be input for VFC as well as adult vaccines (Leslee Minch will send the Adult form sometime before January)
How do I fill it out?Current form was sent out in PDF Fill out by hand then fax or scan & email it to
the programWorking on getting in a fillable PDF form so
you can fill in electronically and send
Identification InformationDate, the actual date you are filling in formCorrect VFC PIN that starts with HPrepared by…this is actual person filling in
form. It may not be VFC contact Provider Name: actual name of your clinic, if
there is more than one in your county you might need to add city: Bell Co HD-Middlesboro & Bell Co HD-Pineville; initials do not help ex. BCHC
Check if new address; you should have already discussed with us before submitting
Identification Information continued:NEW FOR THIS FORM:
Put in office hours (If you want to leave off Friday that is ok since we do not deliver on Friday’s unless it is an emergency.)
Dates closed in next 30 days
VACCINESREQUEST DOSES
PREVIOUS STOCK
ORDERS RECEIVE
D
TRANSFER/
EXPIRED DOSES
DOSES GIVEN
CURRENT STOCK
NDC#
LOT#
EXPIRATION DATE
DTAP
DAPTACEL
10 VIALS
(SANOFI)
INFANRIX
10 SYRINGES (GSK)
INFANRIX
10 VIALS (GSK)
Left column is actual vaccine. Ex is “DTAP.” This form uses all CAPS rather
than DTaP. These are the only brands & presentation we carry
If you do not want us to substitute brand you must write it in on your form somewhere near vaccine, we will do our best but as always cannot guarantee brand
DO NOT start on left columns but in the “current stock” column. Write down EXACT VFC doses you have in your frig. If you have more than 2 lot numbers go to the
back page (example on next slide)
Order Form
• This is page 4 of the order form – use page 4 to record lot numbers if you have more than 2 lot #s of any vaccine.
VACCINESCURRENT
STOCKNDC# LOT#
EXPIRATION DATE
Doses GivenTo find out how many doses given you can
pull a CDP report but must make sure it is all VFC and not private stock or use Activity Worksheet (see example in the next slide)
Activity worksheetThis form is available for your use and is to be
completed by hand (we are working on making it a fillable PDF form)
Put on frig or freezer and check off each vaccine as you pull vaccine dose out of unit
Fill one out monthlyAge of patient is to left, in that box put:
M – Medicaid or one of MCOU – Uninsured or no insuranceN – UnderinsuredK – KCHIPI – American Indian orA – Alaska Native
Activity Worksheet continuePut x or check on line with shot givenMany will have more than one shotDoses given will be how many x’s or check
marks are in the column for that specific vaccine
Be sure to include flu doses administered as we use these data to determine how much to send the next year
Transfer/Expired dosesIf you fill out a Return and Adjustment form
you must fill in that columnIt would be a good idea to send Return form
at the same time you send order
Previous StockGet “previous stock” from your last order
form where it says “current stock”This will be the number of doses you had
after you submitted the previous orderDo each vaccine the same way
PREVIOUS STOCK
ORDERS RECEIVED
TRANSFER/
EXPIRED DOSES
DOSES GIVEN
CURRENT STOCK
100 50 10 50 90
In a perfect world, which we are going towards…your order form should add up.
Eligibility
On page 4 of 4.Use either a CDP report or the Activity
Worksheet to get number of patients.This will be much smaller than the number of
doses given since some patients can get 5 or 6 doses of vaccine. You are reporting patients not doses.
Eligibility category are the same as on the Activity Worksheet
Questions?Contact Kentucky Vaccine Program
502-564-4478 and put in our extension (do not press 1 for Immunization since that goes to LaKeta Ritchie)
(these will all change in November)Rita Lathrem x3914 does HD ordersJudy Baker x3518Laura Harrod x3855Clarissa Wilson x3734
Email inbox is [email protected] 502-696-4923