Forms and Records for the Vaccine for Children (VFC) Program
Online Provider Enrollment Form
Online Provider Reenrollment Form
Links below are Adobe Acrobat PDF files of 185 MB or less and open in new window.
Patient Eligibility
- Patient Eligibility Screening Record, Vaccines for Children Program
- Comprehensive Certification Form for American Indians and Alaskan Natives
- Comprehensive Certification Form for Children Enrolled in Medicaid
- Patient Eligibility Screening Record for Family Planning Clinics
- Unaccompanied Minor without Insurance Information VFC Vaccine Log
Provider Enrollment Forms
- Initial Enrollment Form
- Reenrollment Form
- Disenrollment Form
- Maximum Regional Charges for Vaccine Administration
- Suspected Fraud and Abuse Report Form
Vaccine Reporting Forms
- List of Ordering Schedules by PIN
- Vaccine Report Forms and Ordering Schedules
Providers will now report and order through the Florida SHOTS™ system. Please login. - Vaccine Report Form Additional Page
Other Order Forms
- Varicella-Containing Vaccine Order Form
Providers will now order through the Florida SHOTS™ system. Please login.
Vaccine Management
- Temperature Log for Vaccines (Fahrenheit)
- Temperature Log for Vaccines (Celsius)
- Vaccine Usage Worksheet
- Vaccine Inventory Balance Sheet
- Vaccine Return and Waste Form
Providers will now report and order through the Florida SHOTS™ system. Please login. - Vaccine Transfer Form
Providers will now report and order through the Florida SHOTS™ system. Please login. - Vaccine Order Form for Off-Site Immunization Activities
- Cooler Temperature Log
- Emergency Response Plan
