Vaccine Management Forms

• Reporting Nonviable MDH Vaccine to MIIC (PDF)
  How to use the MDH Nonviable Vaccine Form in MIIC to report nonviable or lost MDH vaccine.

• MDH Vaccine Transfer Record (PDF)
  Form for transferring MDH vaccine to another site in order to prevent vaccine waste.
• VFC Vaccine Borrowing Report (PDF)
  Borrowing occurs when a provider borrows vaccine from MnVFC stock to administer to a patient not eligible for the program, or when a provider borrows vaccine from private stock to use on MnVFC-eligible patients.
• NEW: MnVFC and UUAV Temperature Excursion Form
  Providers are required to use this form to report temperature excursions that affect public (MnVFC or UUAV) vaccine stock. 
  • Temperature Excursion Incident Checklist (PDF)
    Optional checklist to assist in completing the online temperature excursion.
  • Temperature Excursion Incident Log (PDF)
    Use this log (or your own) to document temperature excursions and actions taken.
• Worksheet for Developing an Emergency Plan for Managing Vaccine (PDF)
  Fillable PDF of the worksheet included in the MnVFC Policies and Procedures Manuals. You can find your site's manual on Required Reports and Trainings.
  • Immunize.org: Medical Management of Vaccine Reactions in Children and Teens in a Community Setting (PDF)
    Steps to take if an adverse reaction occurs after vaccination in children and teens.
  • Immunize.org: Medical Management of Vaccine Reactions in Adults in a Community Setting (PDF)
    Steps to take if an adverse reaction occurs after vaccination in adults.
• MDH Vaccine Restitution Appeal Form (PDF)
  Form to file an appeal regarding the waste of the MDH vaccine.