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

         

         

         

         

         

         

         

         

         

After current stock fill in NDC or National Drug Code

Usually on front of box

NDC#

Lot # and expiration dateFill in for each lot you have of each specific

vaccineOne line per lot #

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

Orders receivedSince you sent in your last order, put in all

VFC doses received by your site

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 dph.kvp@ky.govFax 502-696-4923