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
Patient Record Information
03/2013 Patient Eligibility Screening Record Vaccines for Children Program (PDF)
06/2018 Adult Eligibility Screening Record (PDF)
10/2011 Sharing of school health records (Word)
01/2008 Client Vaccine Administration Form Template (Word)
01/2008 Client Exemption Form Moved Or Gone Elsewhere (M.O.G.E.) (Word)
02/2019 ImmPact Patient Non-Participation Form (PDF)
02/2019 ImmPact Patient Re-Enrollment Form (PDF)
Provider Enrollment Agreement
02/2019 Individual Non-Vaccine User Agreement (PDF) – The ImmPact Individual User Agreement will be filled out and signed by the individual user. This form will be faxed to the Maine Immunization Program.
02/2019 Individual - The ImmPact Individual User Agreement (PDF) will be filled out and signed by the individual user, as well as signed by the ImmPact Administrator. This form will be kept on file with the organization and made available to Maine Immunization Program upon request for 4 years.
02/2019 ImmPact Administrator (PDF) - The ImmPact Administrator Agreement will be filled out and signed by the vaccine coordinator (aka super user), as well as signed by the organization's authorizing person. This form will be faxed to ImmPact.
03/2019 Immunization Information System (IIS) Rules (PDF)
02/2019 Immpact User Confidentiality and Security Policy (PDF)
Storage and Handling
02/2013 Vaccine Manufacturer contact information (PDF)
11/27/13 Varicella/MMR-V Eligibility Request Form (Word)
06/2014 Updated Vaccine Storage and Handling Toolkit 2014
08/2015 Recalibration form for thermometer (PDF)
05/2019 Refrigerator Temperature Log (PDF)
05/2019 Freezer Temperature Log (PDF)
01/2008 Storage, Handling, and Emergency Protocol Instructions (Word)
Vaccine Management
04/2010 Use of Open Multidose Vaccine Vials Policy (Word)
02/2009 Order Forms are now specific to the provider site, please call for your specific order form replacement.
Vaccine Replacement Procedure
02/2017 Opportunity Cost Worksheet BLS Wages for Vaccine Support Staff (Excel)
01/2017 Statement of Relacement Sample (PDF)
01/2017 Corrective Action Plan Example (PDF)
01/2017 Vaccine Replacement Plan Sample (PDF)

(If you receive a username/password box for any downloads (PDF or Word), 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