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Vaccines for Children Program (VFC) Program Forms

The table below reflects the forms needed to successfully comply with the regulations governing the Vaccines for Children Program.  Click on each title to bring up the PDF versions of each form described below.


Immunization Program Reporting Record

   Patient Eligibility of       Screening Record

Temperature Log for Vaccines in Freezer-Celsius

Temperature Log for Vaccines in Freezer-Fahrenheit

Temperature Log for Vaccines in Fridge-Celsius

Temperature Log for Vaccines in Fridge-Fahrenheit

Vaccine Administration Record

VFC Program Forms Request

VFC Vaccine Inventory/Order Form

Short-Dated Vaccine Report Form

Vaccine Contingency & Emergency Plan

Vaccine Borrowing Form


VFC FLU Vaccine Order Form


Return to Immunizations - VFC Page

Return to Immunization Program Main Page

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