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Maine Immunization Program > Materials / Forms

Materials / Forms

This page is being developed to provide one location for providers and clients to be able to download the recommended forms and informational materials. Please check back, as we will be making a concerted effort to get most of our available papers on-line.

(If you receive a username/password box for any downloads [.pdf/.doc], click cancel and the document will load)

Provider Enrollment Compliance - (Updated 01/15/2008)

Provider Contract
Client Exemption Form (M.O.G.E.) Client Accountability Form
Client Vaccine Admin Form Vaccine Administration Form
Varicella Eligibility 2008 Varicella Eligibility Form

 

Shipping / Handling and Inventory

EDUCATION/MATERIAL ORDER FORM Order Brochures, Pamphlets, VIS. Etc.
Order Brochures, Pamphlets, VIS, Page 2
VACCINE ORDER FORM 2008 Vaccine Order Form
(form updated 08/18/08)
VACCINE USAGE FORM INSTRUCTIONS State Vaccine Reporting Inst.
VACCINE USAGE FORM
VACCINE TRANSFER Vaccine Transfer Form
VACCINE RETURN FORM Submit Expired and Non-Viable Vaccine
REFRIG LOG 2008-Track Your Frig Temps - Page 1
(form updated 08/18/08)
2008-Track Your Frig Temps - Page 2
(form updated 08/18/08)
FREEZER LOG 2008-Track Your Freezer Temps - Page 1
(form updated 08/18/08)
2008-Track Your Freezer Temps - Page 2
(form updated 08/18/08)
STORAGE PLAN Storage and Emergency Protocol Instructions

 

Fax Completed Forms to: 1-800-569-0659 or 1-207-287-3347
For more information:
Call 287-3746 or 1-800-867-4775
8:00am-5:00pm,  Monday thru Friday