Vaccine Management Forms

Note: Save fillable PDF's to your computer before typing in the form fields.

• MnVFC Nonviable Vaccine Form (PDF)
  Use this form to report nonviable (i.e., spoiled or expired) 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.
• Storage and Handling Mishap Log (PDF)
  Document storage and handling incidents and actions taken.
• Storage and Handling Mishap Checklist (PDF)
  Use this checklist when a storage and handling mishap has occurred.
• 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.
• MDH Vaccine Restitution Appeal Form (PDF)
  Form to file an appeal regarding the waste of the MDH vaccine.