New VFC Order Form: Why do I have to do this? How do I fill it out? By Laura Harrod, KVP Coordinator

Why do we have to do this form? Part of CDC’s Vaccine Management Business Improvement Plan or VMBIP CDC is requiring more accountability of vaccines New 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 & it to the program Working on getting in a fillable PDF form so you can fill in electronically and send

Identification Information Date, the actual date you are filling in form Correct VFC PIN that starts with H Prepared 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

VACCINES REQUEST DOSES PREVIOUS STOCK ORDERS RECEIVED 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. VACCINES CURRENT STOCK NDC#LOT# EXPIRATION DATE

After current stock fill in NDC or National Drug Code Usually on front of box NDC#

Lot # and expiration date Fill in for each lot you have of each specific vaccine One line per lot #

Doses Given To 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)

KVP ACTIVITY WORKSHEET KVP PIN # Provider Name Start Date End Date. For each child please indicate appropriate eligibility status.* DT DTaP IPV HEP A Adult HEP A HEP B Adult HEP B PF HEPB-Hib Hib HPV4 Influenza Kinrix MCV4 MMRV MMR MPSV4 Pediarix Pentacel PNEUMO Prevnar ROTA Td Adult Tdap Varicella <1 year 1-6 yrs 7-18 yrs

Activity worksheet This 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 monthly Age of patient is to left, in that box put: M – Medicaid or one of MCO U – Uninsured or no insurance N – Underinsured K – KCHIP I – American Indian or A – Alaska Native

Activity Worksheet continue Put x or check on line with shot given Many will have more than one shot Doses 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 doses If you fill out a Return and Adjustment form you must fill in that column It would be a good idea to send Return form at the same time you send order

Orders received Since you sent in your last order, put in all VFC doses received by your site

Previous Stock Get “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 order Do each vaccine the same way

PREVIOUS STOCK ORDERS RECEIVED TRANSFER / EXPIRED DOSES DOSES GIVEN CURRENT STOCK 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 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 orders Judy Baker x3518 Laura Harrod x3855 Clarissa Wilson x3734 inbox is Fax