Maine Immunization Program - Information for Providers

Forms and Updates

This page is being developed to provide one location for providers 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.

Date Revised Title

Material Order Forms
01/2012 Order Brochures, Pamphlets, VIS, and More (Microsoft Word*)
Patient Record Information
10/2011 Sharing of school health records (Microsoft Word*)
05/2011 Patient Eligibility Screening Record Vaccines for Children Program (Microsoft Word*)
01/2008 Client Vaccine Administration Form Template (Microsoft Word*)
01/2008 Client Exemption Form Moved Or Gone Elsewhere (M.O.G.E.) (Microsoft Word*)

Provider Enrollment Agreement
12/2011 2012 Provider Agreement Cover Letter (Microsoft Word*)
12/2011 2012 Provider Agreement (Microsoft Word*)
08/2011 ImmPact2 User Agreement (Microsoft Word*)
06/2011 ImmPact2 Rules (Microsoft Word*)
01/2011 Immpact2 user confidentiality and security policy (Microsoft Word*)
12/2010 Immpact2 reenrollment form (Microsoft Word*)
12/2010 Non-Participation Form (Microsoft Word*)
10/2010 ImmPact2 Superintendent Agreement (Microsoft Word*)
09/2010 ImmPact2 schooluser Agreement - school specific (Microsoft Word*)

Storage and Handling
01/2012 Expired or Non-viable Vaccine Return Form (Microsoft Word*)
10/2011 Updated Vaccine Storage and Handling Guide 2011
07/2011 Recalibration form for thermometer (Adobe PDF*)
06/2010 Refrigerator Temperature Tracking Form - Page 1 (Adobe PDF*)
06/2010 Refrigerator Temperature Tracking Form - Page 2 (Adobe PDF*)
06/2010 Freezer Temperature Tracking Form - Page 1 (Adobe PDF*)
06/2010 Freezer Temperature Tracking Form - Page 2 (Adobe PDF*)
01/2008 Storage, Handling, and Emergency Protocol Instructions (Microsoft Word*)

Vaccine Management
01/2012 Pediatric and Adult Use Reporting Process Instructions (word*) 02/07/2011 (Youtube)
06/2010 Submit Expired and Non-Viable State Supplied Vaccine (Microsoft Word*)
04/2010 Use of Open Multidose Vaccine Vials Policy (Microsoft Word*)
02/2009 Order Forms are now specific to the provider site, please call for your specific order form replacement.
01/2008 State Supplied Vaccine Transfer Form (Microsoft Word*)
01/2008 State Supplied Vaccine Usage Reporting Instructions (Microsoft Word*)

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

  • Please feel free to provide feedback or session request through the Support Services call line @ 1-800-867-4775, 8:00am-5:00pm,  Monday thru Friday
  • Fax Completed Forms to: 1-800-437-5743 and 1-207- 287-8127
  • For more information: Call 287-3746 or 1-800-867-4775 8:00am-5:00pm,  Monday thru Friday