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MnVFC Forms
Patient self-screening form
Patient eligibility screening record forms
Annual/semi-annual report forms
Other MnVFC vaccine forms
Subscribe to MnVFC Forms Updates
Online ordering/vaccine order forms
- Ordering instructions and forms have been moved to Ordering MDH Vaccine.
Patient self-screening form
- Can my child get free or low cost shots?
Self-screening form for parents to see if their child is eligible to receive free or low cost shots from MnVFC.
Patient eligibility screening record forms
- Private Clinics:
- Children 18 Years of Age or Younger - PRIVATE (PDF: 54KB/1 page)
MnVFC patient eligibility screening record for private clinics. Revised 9/12
- Children 18 Years of Age or Younger - PRIVATE (PDF: 54KB/1 page)
- Public Clinics:
- Children 18 Years of Age or Younger - PUBLIC (PDF: 34KB/1 page)
MnVFC patient eligibility screening record for local public health (LPH), Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Indian Health System (IHS), and tribal clinics. Revised 9/12
- Children 18 Years of Age or Younger - PUBLIC (PDF: 34KB/1 page)
- Adults 19 Years of Age or Older (PDF: 22KB/1 page)
Use this from to screen adults 19 years of age or older to determine Minnesota Health Program (MHCP) eligibility before administering vaccine. Revised 8/12
Annual/semi-annual report forms
- Annual
Provider Agreement (PDF: 88KB/3 pages)
All public and private healthcare providers seeking enrollment or continued enrollment in the MnVFC program must complete and sign this form and return to MDH by November 30 of each year. We will be unable to process vaccine orders from you after this time without it. Revised 10/12
- Annual Report of the Number of Patients Immunized (PDF: 33KB/1 page)
The Annual Report (a.k.a. Annual Report Form) is an actual count of the number of eligible patients who received MDH vaccine during the previous 12 month period. Due to MDH by November 30. Revised 10/12
- Semi-Annual Report of
Doses Administered to Pediatric Patients - age 0 through 18 years (PDF: 150KB/1 page)
Complete this report only if your clinic is using the replacement method of vaccine supply management. Due to MDH by May 31. Revised 4/13 - Semi-Annual Report of Doses Administered to MHCP Adults - Age 19 years and older (PDF: 109KB/1 page)
Providers who administer vaccine to eligible adults (19 years and older) covered by a Minnesota Health Care Program (MHCP) should complete this report and return it to MDH by May 31. Revised 4/13
Other forms:
- Nonviable MDH Vaccine (PDF: 30KB/1 page)
Use this form to report nonviable (i.e., spoiled or expired) or lost MDH vaccine. Revised 2/13
- MDH Vaccine Transfer
Record (PDF: 26KB/1 page)
Form for transfering MDH vaccine to another provider in order to prevent vaccine waste. Revised 12/11
- MDH Vaccine Restitution Appeal Form (PDF: 29KB/1 page)
Form to file an appeal regarding the waste of the MDH vaccine. Revised 3/11
- VFC Vaccine Borrowing Report (PDF: 129KB/1 pages)
When a provider has borrowed vaccine from one stock to administer to a child who is only eligible to receive vaccine from the other stock, this form must be completely filled out for each borrowing occurrence.
Spotlight
National Infant Immunization Week (NIIW)
Minnesota Immunization Rule Proposed Revisions
Guidance and Training Resources for MIIC Users
Vaccine Clinics Serving Underinsured Children
Uninsured and Underinsured Adult Vaccination Clinics
Current issue of Got Your Shots? News
ACIP Recommendations
Attention: Non-MDH link
Frequently Requested
VISs
CDC fact sheets on vaccines.
Attention: Non-MDH link
CDC Immunization Home
Attention: Non-MDH link
If you have questions or comments about this page, use our IDEPC Comment Form or call 651-201-5414 (TTY: 651-201-5797) for the MDH Infectious Disease Epidemiology, Prevention and Control Division.
