Order Form
Immunization Materials for Professional Use Mail: Minnesota Department of Health Immunization Program P.O. Box 64975
St. Paul, MN 55164-0975
Phone:
1-800-657-3970 651-201-5503
Fax:
651-201-5501
Agency Address
• •
City
State
Phone
Contact
All materials are free of charge. Look for materials under these headings: - ACIP Recommendations - Diphtheria, Pertussis, and Tetanus - Forms for Keeping Track of Immunizations - Hepatitis - Immunization Law - Immunization Schedules - Immunizations, General - Influenza - Measles
Zip
- MnVFC - Mumps - Order Forms for Immunization Materials - Pneumococcal - Reporting: Diseases, Adverse Events - Rubella - Vaccine Storage and Handling - Varicella and Shingles
ACIP Recommendations Comprehensive Recommendations, CDC http://www.cdc.gov/vaccines/pubs/ACIP-list.htm ______
Adolescent: Immunization of Adolescents (11/22/96), 24 pgs
______
Adult: Adult Immunization Programs in Nontraditional Settings, Quality Standards and Guidance for Program Evaluation (3/24/00), 13 pgs
limit 1 of each
______
Adult: Update on Adult Immunization (11/15/91), 16 pgs
______
Adult: Use of Standing Orders Programs to Increase Adult Vaccination Rates (3/24/00), 11 pgs
______
General: General Recommendations on Immunization (12/1/06), 48 pgs
______
Health Care Workers: Immunization of Health Care Workers (12/26/97), 51 pgs
Vaccine-Specific Recommendations, CDC http://www.cdc.gov/vaccines/pubs/ACIP-list.htm ______
HPV: Quadrivalent Human Papillomavirus Vaccine (3/23/07), 32 pgs
______
Hepatitis A: Prevention of Hepatitis A Through Active or Passive Immunization (5/19/06), 37 pgs
______
Hepatitis B - Adults: A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus in the United States (12/8/06), 40 pgs
______
Hepatitis B - Infants, Children, and Adolescents: A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus in the United States (12/23/05), 39 pgs
______
IC#140-0504 (MDH, 9/07)
Influenza: Prevention and Control of Influenza (7/13/07), 60 pgs
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Order Form – Immunization Materials for Professional Use
ACIP Recommendations, continued ______
MMR: Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps (5/22/98), 57 pgs
limit 1 of each
______
Meningococcal: Prevention and Control of Meningococcal Disease (5/27/05), 21 pgs
______
PCV: Preventing Pneumococcal Disease Among Infants and Young Children (10/6/00), 55 pgs
______
PPV: Prevention of Pneumococcal Disease (4/4/97), 24 pgs
______
Pertussis: Use of Acellular Pertussis Vaccines Among Infants and Young Children (3/28/97), 32 pgs
______
Polio: Poliomyelitis Prevention in the United States (5/19/00), 38 pgs
______
Rotavirus: Prevention of Rotavirus Gastroenteritis Among Infants and Children (8/11/06), 16 pgs
______
Tdap - Adolescents: Preventing Tetanus, Diphtheria, and Pertussis, Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines (3/24/06), 50 pgs
______
Tdap - Adults: Preventing Tetanus, Diphtheria, and Pertussis, Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines (12/15/96), 44 pgs
______
Varicella: Prevention of Varicella (6/22/07), 48 pgs
Diptheria, Pertussis, and Tetanus limit 1
Answers to Common Questions About Tdap Vaccine, 1 pg
limit 1
Pertussis Clinical Information, 2 pgs
limit 1
Pertussis—Laboratory Testing, 2 pgs
limit 1
Pertussis Treatment and Prophylaxis, 1 pg
no limit
http://www.health.state.mn.us/divs/idepc/diseases/pertussis/hcp/qatdap.html http://www.health.state.mn.us/divs/idepc/diseases/pertussis/hcp/pfactshcp.html http://www.health.state.mn.us/divs/idepc/diseases/pertussis/hcp/labfacts.html
http://www.health.state.mn.us/divs/idepc/diseases/pertussis/hcp/treatment.html
Summary Guide to Tetanus Prophylaxis in Routine Wound Management, 1 pg chart http://www.health.state.mn.us/divs/idepc/diseases/pertussis/tetwdmgmt.html
limit 1
Tetanus Clinical Information, 2 pgs
limit 1
Tetanus, Diptheria, and Pertussis (Tdap) Vaccine, 1 pg
IC#141-0332
http://www.health.state.mn.us/divs/idepc/diseases/tetanus/hcp/clinical.html http://www.health.state.mn.us/divs/idepc/diseases/pertussis/hcp/tdapvax.html
Forms for Keeping Track of Immunizations Adult Immunization Record, form no limit
http://www.health.state.mn.us/divs/idepc/immunize/hcp/forms.html
_____ Cardstock IC#140-0497 limit 1 of each
_____ Chart Sticker IC#140-0500
Adult Vaccine Administration Record, form used to record patient signatures during vaccination clinics http://www.health.state.mn.us/divs/idepc/immunize/hcp/vaccadmin.html ______ English IC#140-0510
______ Somali
______ Spanish
limit 1
Child Care Immunization Record, form
limit 1
ECFE/School Readiness Immunization Record, form
limit 1
ECSE Immunization Record, form
limit 1
Immunization Record for Students Attending Post-Secondary Schools in MN, form
limit 1
Patient Immunization Record, form
http://www.health.state.mn.us/divs/idepc/immunize/tracking.html http://www.health.state.mn.us/divs/idepc/immunize/tracking.html http://www.health.state.mn.us/divs/idepc/immunize/tracking.html http://www.health.state.mn.us/divs/idepc/immunize/laws/schlaw.html http://www.health.state.mn.us/divs/idepc/immunize/hcp/forms.html
IC#140-0504 (MDH, 9/07)
IC#140-0163 IC#140-0474 IC#140-0472 IC#140-0473 IC#140-0593
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Order Form – Immunization Materials for Professional Use
Forms for Keeping Track of Immunizations, continued Pediatric Immunization Record Card, form no limit
http://www.health.state.mn.us/divs/idepc/immunize/hcp/forms.html
_____ Cardstock IC#140-0498 limit 1 of each
_____ Chart Sticker IC#140-0501
Pediatric Vaccine Administration Record, form used to record patient signatures during vaccination clinics http://www.health.state.mn.us/divs/idepc/immunize/hcp/vaccadmin.html ______ English IC#140-0509
______ Somali
______ Spanish
Hepatitis limit 1
Hepatitis A Vaccine Products and Scheduling Chart, 1 pg
limit 1
Hepatitis B Virus Nomenclature and Interpretation of Laboratory Tests, 1 pg
no limit limit 1 no limit limit 1
http://www.health.state.mn.us/divs/idepc/diseases/hepa/hcp/vaccine.html http://www.health.state.mn.us/divs/idepc/diseases/hepb/hcp/index.html
IC#141-0586
Perinatal Hepatitis B Carrier Follow-Up Report, form http://www.health.state.mn.us/divs/idepc/diseases/hepb/perinatal/reporting.html
Perinatal Hepatitis B Hospital Report, 1 pg http://www.health.state.mn.us/divs/idepc/diseases/hepb/perinatal/hcp.html
Perinatal Hepatitis B Prevention Pocket Guide http://www.health.state.mn.us/divs/idepc/diseases/hepb/perinatal/pocket.html
IC#141-0837
Perinatal Hepatitis B Prevention Protocols, 4 pgs http://www.health.state.mn.us/divs/idepc/diseases/hepb/perinatal/clinical.htm
Stop Hepatitis B for Every Baby, 11” x 17” poster http://www.health.state.mn.us/divs/idepc/diseases/hepb/perinatal/hcp.html no limit
_____ Check Every Pregnant Woman’s Hep B Status IC#141-1689 _____ HBsAg Test ALL Pregnant Women IC#141-1688
Immunization Law no limit
Healthy Kids Are Everybody's Job: A Guide to Minnesota's Immunization Law for Child Care Providers, 6 pg pamphlet http://www.health.state.mn.us/divs/idepc/immunize/healthykidsprov.html
limit 1
Minnesota's School Immunization Law: Questions and Answers, 14 pgs
limit 1
Provider's Quick Reference on Minnesota's Immunization Laws, 2 pgs
IC#141-0210
http://www.health.state.mn.us/divs/idepc/immunize/school/index.html http://www.health.state.mn.us/divs/idepc/immunize/laws/qreflaws.html
Immunization Schedules no limit
Recommended Adult Immunization Schedule, 2 pgs
no limit
Recommended Childhood Immunization Schedule, 4 pgs
http://www.health.state.mn.us/divs/idepc/immunize/hcp/schedules.html http://www.health.state.mn.us/divs/idepc/immunize/hcp/schedules.html
IC#141-0316 IC#141-0188
Immunizations, General
(rolls of 100)
limit 15
Ask Me About Your Child's Shots, button
IC#141-0212
limit 10
Got Your Shots?, 2” x 4” magnet
IC#141-0251
no limit
Got Your Shots?, sticker TO BE DISCONTINUED, AVAILABLE WHILE SUPPLY LASTS
IC#141-0252
Got Your Shots? News, sign up to receive a monthly immunization update from the MDH Immunization Program n/a
http://www.health.state.mn.us/divs/idepc/newsletters/gys/index.html
Email: ________________________________ Fax: _______________________________ IC#140-0504 (MDH, 9/07)
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Order Form – Immunization Materials for Professional Use
Immunizations, General, continued limit 1 no limit limit 10
How to Administer IM/SQ Injections, 2 pg chart http://www.health.state.mn.us/divs/idepc/immunize/hcp/vaccine.html
Provider Information on MIIC (Minnesota Immunization Information Connection), pamphlet Six Common Misconceptions About Vaccination and How to Respond to Them, CDC, 10 pgs http://www.cdc.gov/nip/publications/6mishome.htm
IC#141-0334
limit 1
Six Steps Toward Cultural Competence, Center for Cross-Cultural Health, 20 pgs
IC#141-0270
limit 1
Standards for Adult Immunization Practices, 1 pg
IC#141-1507
limit 1
Standards for Child and Adolescent Immunization Practices, 1 pg
IC#141-1490
limit 1
Action Steps to Increase Flu Vaccination Rates of Healthcare Personnel, 2 pgs
limit 1
Be Part of the Influenza Sentinel Surveillance Program, 1 pg
limit 1
Healthcare Facility Employee Influenza Vaccination, consent form
limit 1
Improving Influenza Vaccine Rates in Health Care Workers, National Foundation for Infectious Disease, 24 pgs
Influenza http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/actionsteps.html http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/sentinel.html http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/emplyvaxform.html
http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/vaxhcw.html limit 1
Influenza Immunization Among Health Care Workers: Call to Action, National Foundation for Infectious Disease, 4 pgs http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/vaxhcw.html
no limit
Influenza Vaccination Pocket Guide, Immunization Action Coalition
IC#141-1227
limit 1
Live Attenuated Influenza Vaccine (LAIV): A Safe Choice for Healthcare Workers, 2 pgs
llimit 1
Proper Storage, Handling, and Shipping of Influenza Vaccine, 2 pgs
limit 1
Seven Truths About Influenza Vaccination of Healthcare Workers, 1 pg
limit 1
Use of Antiviral Agents for Influenza Treatment and Prophylaxis, 3 pgs
limit 1
What Should Schools Do About Influenza?, 1 pg
limit 1
When to Report Influenza and Submit Clinical Materials, 1 pg chart
limit 1
Lab Testing for Measles, 2 pgs
limit 1
Measles Clinical Information, 3 pgs
limit 1
Annual Provider Enrollment Agreement, form to participate in the MnVFC program
limit 1
Annual Report of the Number of Patients Immunized Through the MnVFC Program, form to submit annual totals of patients served by the MnVFC program
http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/laiv.html http://www.health.state.mn.us/divs/idepc/diseases/flu/storage.html http://www.health.state.mn.us/divs/idepc/diseases/flu/hcp/seventruths.html http://www.health.state.mn.us/divs/idepc/diseases/flu/ltc/antivirals.html http://www.health.state.mn.us/divs/idepc/diseases/flu/school/closings.html http://www.health.state.mn.us/divs/idepc/dtopics/reportable/influenza.html
Measles http://www.health.state.mn.us/divs/idepc/diseases/measles/hcp/labtesting.html http://www.health.state.mn.us/divs/idepc/diseases/measles/hcp/clinical.html
MnVFC http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
IC#140-0504 (MDH, 9/07)
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Order Form – Immunization Materials for Professional Use
MnVFC, continued limit 1 of each
Patient Eligibility Screening Record, form to document the eligibility of MnVFC clients http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
_____ Form for General MnVFC Providers
_____ Form for Local Public Health Agencies
limit 1
Policies and Procedures Manual for the MnVFC Program, 28 pgs
limit 1
Provider Profile for Initial Enrollment in MnVFC, form to enroll in the MnVFC program
limit 1 of each
http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
Report of Doses Administered, form for providers who use the optional “replacement” method of managing their vaccine http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
_____ Doses Administered to Pediatric Patients Age 0 through 18 Years _____ Doses Administered to Adult Patients 19 years and Older
limit 1
Returned Non-Viable Vaccine, form for returning expired or spoiled vaccine to the MnVFC program
limit 1
Using MnVFC to Provide Patients with Free or Low-Cost Immunizations, 2 pgs
limit 1 of each
http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
Vaccine Order Forms http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
_____ All MnVFC Vaccines
_____ Influenza Vaccine
_____ Varicella Vaccine
limit 1
Vaccine Transfer Record, form to redistribute vaccine to another MnVFC provider
limit 1
Lab Testing for Mumps, 1 pg
limit 1
Mumps Clinical Information, 1 pg
limit 1
Mumps Prevention and Control in Healthcare Settings, 5 pgs
limit 1
Mumps Vaccination and Disease History Status Assumptions by Age, 1 pg
http://www.health.state.mn.us/divs/idepc/immunize/mnvfc/index.html
Mumps http://www.health.state.mn.us/divs/idepc/diseases/mumps/hcp/labtesting.html http://www.health.state.mn.us/divs/idepc/diseases/mumps/hcp/clinical.html http://www.health.state.mn.us/divs/idepc/diseases/mumps/hcp/infcontrol.html http://www.health.state.mn.us/divs/idepc/diseases/mumps/hcp/assump.html
Order Forms for Immunization Materials Order Forms for Immunization Materials, some materials are listed on more than one order form http://www.health.state.mn.us/divs/idepc/immunize/ordermat.html
limit 1 of each
______ Immunization
Materials for Child Care Programs IC#140-0488
______ Immunization
Materials for Professional Use IC#140-0504
______ Immunization
Materials for Use with the Public IC#140-0505
______ Immunization
Materials in Languages Other Than English IC#140-0506
______ Immunization
Materials Useful for WIC IC#140-0638
______ Influenza
Immunization Materials IC#140-0637
______ Newborn
Immunization Folder IC#140-0490
______ Perinatal
Hepatitis B Materials IC#140-2325
Pneumococcal no limit
Pneumococcal Vaccination Pocket Guide http://www.health.state.mn.us/divs/idepc/diseases/pneumococcal/hcp/pocket.html
IC#140-0504 (MDH, 9/07)
IC#141-0837
Page 5 of 6
Order Form – Immunization Materials for Professional Use
Reporting: Diseases, Adverse Events (see also specific diseases) no limit
Disease Report Card ("Yellow Card"), form
no limit
Diseases Reportable to MDH, poster
limit 1
http://www.health.state.mn.us/divs/idepc/dtopics/reportable/forms/reptcard.html http://www.health.state.mn.us/divs/idepc/dtopics/reportable/rule/poster.html
IC#140-0093 IC#141-0075
Vaccine Adverse Events Reporting System (VAERS), U.S. Department of Health and Human Services, form http://www.vaers.hhs.gov/default.htm
Rubella limit 1
Lab Testing for Rubella, 2 pgs
limit 1
Rubella Clinical Information, 2 pgs
http://www.health.state.mn.us/divs/idepc/diseases/rubella/hcp/labtesting.html http://www.health.state.mn.us/divs/idepc/diseases/rubella/hcp/clinical.html
Vaccine Storage and Handling no limit
Do Not Unplug, sticker
IC#141-0385
no limit
Keep Vaccines Safe, 5” x 7” magnet
IC#399-1744
limit 1
Vaccine Handling Tips, 2 pgs http://www.health.state.mn.us/divs/idepc/immunize/hcp/vaxhandling.html
no limit
Vaccine Storage Temperature Log (Celsius), 25 sheets/pad
no limit
Vaccine Storage Temperature Log (Fahrenheit), 25 sheets/pad
http://www.health.state.mn.us/divs/idepc/immunize/hcp/vaccine.html
IC#141-0110 IC#141-2232
http://www.health.state.mn.us/divs/idepc/immunize/hcp/vaccine.html
IC#141-2233
no limit
Warning-- Do Not Break Circuit or Unplug Refrigerator/Freezer, sticker
IC#141-0383
no limit
Who to Call About Vaccine Storage Mishaps, magnet
Varicella and Shingles limit 1
Chickenpox and Shingles: School Reporting and Outbreak Recommendations, 2 pgs
limit 1
Minnesota Chickenpox School Outbreak Report, form
limit 1
Zoster (Shingles) Case Report, form
http://www.health.state.mn.us/divs/idepc/diseases/varicella/schoolrptrecs.html http://www.health.state.mn.us/divs/idepc/diseases/varicella/schoolreporting.html http://www.health.state.mn.us/divs/idepc/diseases/varicella/schoolreporting.html
Comments or questions:
IC#140-0504 (MDH, 9/07)
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