Vaccine Provider Enrollment Package

Vaccine Provider Enrollment Packet

• The 2012 Vaccine Distribution Enrollment has begun. The Provider Agreement Form will be submitted online through VacTrAK this year. To view detailed instructions on how to access and submit the online Provider Agreement Form, see the Alaska Vaccine Distribution Provider Agreement Instructions (2012).
• Alaska Vaccine Distribution Handbook (February 2012)
• Alaska Vaccine Distribution Provider Agreement Instructions (2012)

VFC Forms

• VFC Eligibility Flow Chart For Providers Receiving State-Supplied Vaccine
• VFC Eligibility Screening Form
• VFC Vaccine Borrowing Form (CDC)
• "Do Not Unplug" Signs

Vaccine Distribution Program Forms

• State-Supplied Vaccine Management Form
• State-Supplied Vaccine Administration Form
• Vaccine Return & Facility Incident Report Forms
• Emergency / Power Outage Plan for Vaccines
• Emergency / Power Outage Plan for Vaccines (editable)
• Vaccine Temperature Log
• Vaccine Transfer Form
• Counter Top Display Sign
• Vaccine Adverse Event Reporting Form (VAERS)

Vaccine Information Statements

• Multiple Vaccine - This 4-page VIS may be used as an optional substitute for any or all of the routine birth-6 month vaccine VISs: DTaP, IPV, Hib, PCV, Hepatitis B, and Rotavirus.

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