Provider Request for Vaccine

Request for Vaccine
Provider ID Number:	Provider Name:
Contact Person:	Telephone Number:	Email Address:

Answer the Following Questions:

1. Within the past month, have you submitted to the NDDoH the temperature logs for your VFC vaccine storage units?YesNo
   • Are the recorded temperatures in the storage units within the required ranges? YesNo  
2. Have you submitted a doses administered report to the NDDoH? YesNo

Vaccine Type	Packaging	Unit Size	Doses Ordered	Doses On Hand
DTaP - Infanrix	Syringes	10
DTaP - Infanrix	Single-dose vials	10
DTaP - Daptacel	Single-dose vials	10
DTaP-IPV/Hib - Pentacel	Single dose vials	5
DTaP/HepB/IPV - Pediarix	Syringes	10
DTaP-IPV - Kinrix	Single-dose vials	10
DTaP-IPV - Kinrix	Syringes	10
Hepatitis A - Vaqta	Single-dose vials	10
Hepatitis A - Havrix	Single-dose vials	10
Hepatitis A - Havrix	Syringes	10
Hepatitis B - Engerix B	Syringes	10
Hepatitis B - Engerix B	Single-dose vials	10
Hepatitis B - Recombivax	Single-dose vials	10
Hib - PedvaxHIB	Single-dose vials	10
Hib - ActHIB	Single-dose vials	5
HPV4 - Gardasil	Single-dose vials	10
IPV - i-pol	Multi-dose vials	10
Meningococcal Conjugate (MCV-4) - Menactra	Single-dose vials	5
Meningococcal Conjugate (MCV4) - Menveo	Single-dose vials	5
MMR - MMRII	Single-dose vials	10
Pneumococcal Conjugate (PCV-13) - Prevnar 13	Syringes	10
Pneumococcal Polysaccharide (PPV-23) - Pneumovax	Multi-dose vials	5
Rotavirus - Rotateq	Single dose tubes	10
Rotavirus - Rotarix	Single dose tubes	10
Tdap - Adacel	Syringes	5
Tdap - Adacel	Single-dose vials	10
Tdap - Boostrix	Single-dose vials	10
Tdap - Boostrix	Syringes	10
Varicella - Varivax	Single-dose vials	10
Td* - Decavac	Syringes	10
Td* - Decavac	Single-dose vials	10
Td* - (MassBiologics)	Syringes	10
Influenza - 6 - 35 months	0.25 mL syringes	10
Influenza - 3 - 18 years	0.5 mL syringes	10
Influenza - 3 - 18 years	0.5 mL vials	10
Influenza - 6 months - 18 years	Multi-dose vial	10
Influenza - 2 - 18 years (FluMist)	0.2 mL sprayer	10

HBIG and pediatric DT are also available for order. Please contact the ND Immunization Program for approval and ordering information.

*Available for use in children (>= 7 years) who have not completed the primary series of DTaP.

Explanation for large orders and/or special delivery instructions: