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?
    • Are the recorded temperatures in the storage units within the required ranges?   
  2. Have you submitted a doses administered report to the NDDoH?
Vaccine TypePackagingUnit SizeDoses OrderedDoses On Hand
DTaP - InfanrixSyringes10
DTaP - InfanrixSingle-dose vials10
DTaP - DaptacelSingle-dose vials10
DTaP-IPV/Hib - PentacelSingle dose vials5
DTaP/HepB/IPV - PediarixSyringes10
DTaP-IPV - KinrixSingle-dose vials10
DTaP-IPV - KinrixSyringes10
Hepatitis A - VaqtaSingle-dose vials10
Hepatitis A - HavrixSingle-dose vials10
Hepatitis A - HavrixSyringes10
Hepatitis B - Engerix BSyringes10
Hepatitis B - Engerix BSingle-dose vials10
Hepatitis B - RecombivaxSingle-dose vials10
Hib - PedvaxHIBSingle-dose vials10
Hib - ActHIBSingle-dose vials5
HPV4 - GardasilSingle-dose vials10
IPV - i-polMulti-dose vials10
Meningococcal Conjugate (MCV-4) - MenactraSingle-dose vials5
Meningococcal Conjugate (MCV4) - MenveoSingle-dose vials5
MMR - MMRIISingle-dose vials10
Pneumococcal Conjugate (PCV-13) - Prevnar 13Syringes10
Pneumococcal Polysaccharide (PPV-23) - PneumovaxMulti-dose vials5
Rotavirus - RotateqSingle dose tubes10
Rotavirus - RotarixSingle dose tubes10
Tdap - AdacelSyringes5
Tdap - AdacelSingle-dose vials10
Tdap - BoostrixSingle-dose vials10
Tdap - BoostrixSyringes10
Varicella - VarivaxSingle-dose vials10
Td* - DecavacSyringes10
Td* - DecavacSingle-dose vials10
Td* - (MassBiologics)Syringes10
Influenza - 6 - 35 months0.25 mL syringes10
Influenza - 3 - 18 years0.5 mL syringes10
Influenza - 3 - 18 years0.5 mL vials10
Influenza - 6 months - 18 yearsMulti-dose vial10
Influenza - 2 - 18 years (FluMist)0.2 mL sprayer10

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: