Vaccine Order Form - Vaccines for Children Program
                                         
Complete information in boxes one through four. This form should be submitted with the VFC Vaccine Usage Worksheet, the WV Vaccine on Hand Report and the Temperature Log.  If PIN number is unknown or assistance is required, call the Immunization Program at (800) 642-3634.

1. Date submitted:					2. VFC PIN (state assigned):	
3. Facility name:	

Vaccines	Brand	Manufacturer	Packaged	Doses Ordered	
DT*   <7yrs old	Pediatric Use	Sanofi Pasteur	1 dose vial		
DTaP <7yrs old	Tripedia	Sanofi Pasteur	10 x 1 dose vial		
DTaP <7yrs old	Daptacel	Sanofi Pasteur	10 x 1 dose vial		
DTaP <7yrs old	Infanrix	GlaxoSmithKline	5 x 1 dose syringe		
DTaP <7yrs old	Infanrix	GlaxoSmithKline	10 x 1 dose vial		
DTAPHBIP	Pediarix	GlaxoSmithKline	10 x 1 dose vial		
DTAPHBIP	Pediarix	GlaxoSmithKline	5 x 1 dose syringe		
DTaPIPHI	Pentacel	Sanofi Pasteur	5 x 1 dose vials		
DTaP/IPV(4-6yrs)	Kinrix	GlaxoSmithKline	5 x 1 dose syringe		
DTaP/IPV(4-6yrs)	Kinrix	GlaxoSmithKline	10 x 1 dose vials		
EIPV	IPOL	Sanofi Pasteur	10 dose vial		
EIPV	IPOL	Sanofi Pasteur	10 x 1 dose syringe		
HEP A	Vaqta	Merck	10 x 1 dose vial		
HEP A	Havrix	GlaxoSmithKline	5 x 1 dose syringe		
HEP A	Havrix	GlaxoSmithKline	10 x 1 dose vial		
HEP B-PF	Recombivax	Merck	10 x 1 dose vial		
HEP B-PF	Engerix	GlaxoSmithKline	5 x 1 dose syringe		
HEP B-PF	Engerix	GlaxoSmithKline	10 x 1 dose vial		
HIB (pediatric)	ActHib	Sanofi Pasteur	5 x 1 dose vial		
HIB (pediatric)	Pedvax	Merck	10 x 1 dose vial		
HPV	Gardasil	Merck	10 x 1 dose vial		
MCV4	Menactra	Sanofi Pasteur	5 x 1 dose vials		
MMR	MMR	Merck	10 x 1 dose vial		
PNEUMO	Pneumovax	Merck	5 dose vial		
PNU 7(pediatric)	Prevnar	Wyeth	10 x 1 dose syringe		
ROTA(6wk-8mo)	Rotarix	GlaxoSmithKline	10 x 1 dose applicator		
ROTA(6wk-8mo)	Rotateq	Merck	10 x 1dose tube		
TD  > 7yrs old	Td adult	MBL (Akorn)	10 x 1  dose vials		
TDAP 	Adacel	Sanofi Pasteur	5 x 1 dose syringe		
TDAP 	Adacel	Sanofi Pasteur	10 x 1 dose vial		
TDAP 	Boostrix	GlaxoSmithKline	5 x 1 dose syringe		
TDAP 	Boostrix	GlaxoSmithKline	10 x 1 dose vial		
Varicella	Varivax	Merck	10 x 1 dose vial		

* Pediatric DT may not be ordered on-line through WVSIIS.  If a dose(s) of DT is needed, please contact the Immunization Program           
   by telephone at 1-800-642-3634.

4. Signature: ____________________________________________________________________________________________

Please comment on special circumstances requiring unusually high amounts of vaccine requested on this order: 

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Delivery Changes: ________________________________________________________________________________________