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)
11/2020 ImmPact Patient Non-Participation Form (PDF): Please note that due to the federal CDC reporting requirement, the ImmPact Patient Non-Participation Form cannot be used to remove COVID-19 administration documentation.
02/2019 ImmPact Patient Re-Enrollment Form (PDF)
Provider Enrollment Agreement
04/2023 Individual User Agreement (PDF)
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)
01/2019 Updated Vaccine Storage and Handling Toolkit 2019 (PDF)
09/2023 Recalibration form for thermometer (PDF)
05/2019 Refrigerator Temperature Log (PDF)
11/2022 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 Policy
5/2023 Corrective Action Plan (Excel)
5/2023 Statement of Replacement (Excel)
5/2023 Vaccine Replacement Plan (Excel)

(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
  • Email Completed Forms to: immpact.support@maine.gov
  • For more information: Call 287-3746 or 1-800-867-4775 8:00am-4:30pm,  Monday thru Friday