Forms and Tools

All the forms and tools you need as an IPI advisor.

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Forms on this page:
Sample Letters

IPI Program Forms

  • MnVFC Visit Summary (PDF)
    Summary of items needing improvement and/or follow-up from the MnVFC site visit. Updated 3/15
  • MnVFC Visit Cover Sheet (PDF)
    This form is completed with EACH and EVERY type of visit, i.e., MnVFC Site Visit, Educational, or Follow-up. This form has the basic demographic information on the clinic and the IPI person doing the visit. It is also the checklist for which forms need to be sent to MDH. Updated 3/15
  • Educational Visit Form (PDF)
    Formal presentation to clinic staff where an agenda, PowerPoints, and handouts are produced. Complete the Visit Cover sheet along with this form and include any materials and a list of attendees. Updated 3/15
  • Follow-Up Form (PDF)
    Complete this form as you do follow-up to address issues found on a MnVFC site visit. Updated 3/15


  • Transporting Refrigerated Vaccine (PDF)
    A resource from the California Department of Public Health's EZIZ website with information on proper storage and handling of refrigerated vaccine. Attention: Non-MDH link
  • Clinician's Vaccine Mishap Checklist (PDF)
    A checklist for clinical staff that find themselves with a vaccine storage and handling mishap. Updated 5/14

  • Vaccine Storage Guide
    Two-page illustrated guide to vaccine storage temperatures and where and how to store vaccine in a refrigerator-only unit, freezer-only unit, and combination refrigerator/freezer unit. Includes tips for proper storage and management of vaccines.

Sample Letters

Below are sample letters IPI Advisors may use when communicating with clinics. Please only use as a guide. Updated 4/14

Updated Wednesday, February 03, 2016 at 01:51PM