immunisation program vaccine order form · • step 1 to email the completed form to ....
TRANSCRIPT
IMMUNISATION PROGRAM VACCINE ORDER FORM• If you are not completing this form electronically, please print all information clearly.• Vaccine orders can be submitted monthly.
to email the completed form to [email protected]• Step 1• Step 2 reset your form
Has your vaccine refrigerator maintained temperatures between +2°C and +8°C since your last vaccine order? YES NO If no, please complete and submit the ‘cold chain breach report form’ as soon as possible.
Order date VSP Number
Practice Name
Delivery address Email address
Telephone number Fax number
Disease Programs Vaccine brand
Total Stock
on Hand
Vaccine Expiry Date/s
Quantity Required
DTPa-hep B-IPV-Hib Childhood – 6 weeks, 4 & 6 months Infanrix Hexa Office use only
Pneumococcal 13vPCV Childhood – 6 weeks, 4 & 12 months, Medically at-risk & ATSI – 6 weeks, 4, 6 & 12 months Prevenar 13
Office use only
Rotavirus Childhood – 6 weeks & 4 months Rotarix (oral) Office use only
Meningococcal ACWY Childhood – 12 months, Year 10 students & catch up 15 to 19 years Nimenrix
Office use only
Measles-mumps-rubella Childhood – 12 months Catch up – those born during or since 1966 & refugees
Priorix Office use only
MMRII Haemophilus Influenzae type b Childhood – 18 months Act-Hib Office use only
Measles-mumps-rubella- varicella Childhood – 18 months
Priorix-tetra Office use only
ProQuad
Diphtheria-tetanus-pertussis Childhood – 18 months Infanrix Office use only
Tripacel
Diphtheria-tetanus- pertussis-poliomyelitis Childhood – 4 years
Infanrix-IPV Office use only
Quadracel Hepatitis A ATSI children at 12 & 18 months Vaqta paediatric Pneumococcal 23vPPV Medically ‘at risk’, ATSI 50+ & 65+ years Pneumovax 23 Varicella zoster (shingles) Adults from 70 to 79 years Zostavax
Diphtheria-tetanus-pertussis Pregnant women from 20 to 32 weeks gestation, Year 7 students & catch up to 19 years
Adacel Boostrix
Human papillomavirus Year 7 students & catch up to 19 years Gardasil 9
Hepatitis B paediatric Birth dose – maternity hospitals, Catch up – up to 10 years & 16 to 19 years
Engerix paediatric H-B-VaxIIpaediatric
Chickenpox Catch up – 10 to 19 years & refugees Varivax
Hepatitis B adult At risk groups
Engerix B adult H-B-VaxIIadult
Injectable poliomyelitis Catch up – 10 to 19 years & refugees IPOL Meningococcal C Catch up – 10 to 14 years NeisVac-C Other:
Rabies Hospital use only Rabipur Office use only
Rabies immunoglobulin (RIG) Hospital use only Imogam
Influenza vaccines 2020 6 months to 64 years
Vaxigrip Tetra
Fluarix Tetra FluQuadri
5 years to 64 years Afluria Quad 65 years and over Fluad Quad
March 2020
YES NO