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Available Forms

Vaccine VFC Eligibility Screening

Vaccines for Children (VFC) Program Patient Eligibility Screening Record


A record of all children 18 years of age or younger who receive iC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure the child's eligibility status has not changed. While Verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine. Providers using a similar form must capture all reporting elements included in this form.

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