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General Information
- Immunization Program
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) |
| 03/2020 | MMR-V Eligibility Request Form (PDF) |
| 01/2019 | Updated Vaccine Storage and Handling Toolkit 2019 (PDF) |
| 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. |
(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
