(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.
ONLY USE BLUE OR BLACK BALLPOINT PEN
DO NOT USE PENCIL OR FELT-TIP PENS.
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
Family Practice”, record “Jones Family Practice”.
Record the street address and city for your facility on the first page of the logs. Only required on the first page.
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”.
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
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.
Legibly print the full name of the patient in the appropriate areas for last name, first name, and middle initial.
Print the date of birth as “MM DD YYYY”. Fill in the full year i.e., “1999, 2000, etc” (ex: 03-24-2000).
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
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)
N = Not insured (no health insurance)
I = Insured (insurance covers immunizations)
Print the service date as “MM DD YY”.
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.
If you give a patient a dose of MMR, please fill in the circle under MMR.
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.
Total the number of doses given in each vaccine column. Record column totals at the bottom of every page.
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.
You must keep your copy, Part 3 (pink copy) for 3 years.
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
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