Vaccines Administered Log (Page 2 of 2) in pdf

PURPOSE:

(1) To improve accuracy of doses administered reporting; (2) to meet state and federal requirements; (3) to fulfill Vaccines fo r Children (VFC)

documentation requirements; and (4) to provide patient specific immunization information to local health departments.

INSTRUCTIONS:

ONLY USE BLUE OR BLACK BALLPOINT PEN

DO NOT USE PENCIL OR FELT-TIP PENS.

*Report Month:

Fill in month and year on every page. Please do not include more than one MONTH on a VAL form. Additions and corrected copies from different

months should be documented on separate VAL forms rather than on the VAL form(s) for the current month being reported.

* Federal ID

Record the 9 digit federal tax identification number and the 2 digit site number for your FACILITY that has been assigned to you by the

number and two

Immunization Branch as an identifier. The two-digit number is necessary to differentiate between facilities owned by the same group.

digit site number

Record the 11 digit number on every page.

Record the official name of your FACILITY on every page of the log. For example, if Dr. Jones is the solo physician in a facility called “Jones

*Provider Name:

Family Practice”, record “Jones Family Practice”.

* Address:

Record the street address and city for your facility on the first page of the logs. Only required on the first page.

*Page___of ___:

Number every page. Include total number of pages on the first and last page submitted, i.e. “Page 1 of 24”, “Page 24 of 24”.

*Contact Person:

Print the name and telephone number of the contact person 1) whose responsibility it is to ensure the logs are received by the North Carolina

*Contact Phone:

Immunization Program (NCIP) by the 10

of each month, and 2) whom you want the Immunization Branch to call with questions.

Only required on the first page.

*Zero Doses Given:

If no vaccines were given during the month, complete the top of the form, fill in the circle indicating that zero doses were gi ven in this month and mail

form to the Immunization Branch by the 10

of the month.

*Patient Name:

Legibly print the full name of the patient in the appropriate areas for last name, first name, and middle initial.

*Birth Date:

Print the date of birth as “MM DD YYYY”. Fill in the full year i.e., “1999, 2000, etc” (ex: 03-24-2000).

*Eligibility

Fill in the appropriate circle. Only fill in one circle. If a patient qualifies under more than one eligibility category, fill in the first eligibility category

Insurance:

for which the patient is eligible. For example: if the patient is American Indian and Medicaid, fill in “A”. If you can not obt ain information as to

whether a patient’s insurance covers immunizations, fill in “I”.

A = American Indian or Alaska Native

U = Underinsured (only at LHD, FQHC, RHC & Deputized Providers-insurance does not cover the cost of immunizations)

H = NC Health Choice for Children (NC =s CHIP plan)

M= Medicaid

N = Not insured (no health insurance)

I = Insured (insurance covers immunizations)

*Service Date:

Print the service date as “MM DD YY”.

*Vaccine Type

For each patient, record the vaccine type given to a patient on that date. Use this column for state supplied vaccine only.

Do not record any historical data or privately purchased vaccine in this column.

For example:

♦

If you give a patient a dose of MMR, please fill in the circle under MMR.

*Notes:

Record privately purchased vaccine given to a patient who does not meet the coverage criteria under the NCIP.

Space can also be used to document lot number, manufacturer name, expiration date, date printed on Vaccine Information Statemen t (VIS), date VIS

given, chart number, brand/type, etc. Use of this space is not required.

*Column Totals:

Total the number of doses given in each vaccine column. Record column totals at the bottom of every page.

*Preparation:

1. Complete the log and return Part 1 (white copy) and Part 2 (yellow copy) to the Immunization Branch. Keep Part 3 (pink copy) for your files.

2. MAIL Part 1 (white copy) and Part 2 (yellow copy) to: Immunization Branch, 1917 Mail Service Center, Raleigh, NC 27699-1917. The logs

must be received by the Immunization Branch by the 10

of each month. The Immunization Branch will mail the copy to the local health

department in your county. DO NOT FAX OR EMAIL. Faxes or emails will not be accepted.

*Disposition:

You must keep your copy, Part 3 (pink copy) for 3 years.

*Mistakes:

If you make a mistake, draw a line through the entire row that includes the incorrect data. Verify that corrections are transferred to all copies.

State of North Carolina • Department of Health and Human Services • Division of Public Health

Women’s and Children’s Health Section • Immunization Branch

• /divisions/dph

NC DHHS is an equal opportunity employer and provider. 10,000 copies of this document were printed at a cost of $1,916.52 or $0.19 each.

VACCINES ADMINISTERED LOG, VAL122, 5/2016

Vaccines Administered Log Page 2

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