VFC Vaccine Usage Worksheet
		
Provider Name:		Numbers are required for this report.  Do not send with hash marks/check marks.  

There are separate forms for requesting vaccines and reporting balances on hand, expiration, spoilage and wastage.	
Pin Number:			
Usage from:	Date:	to	Date:		
Contact Name:			
                                                                                                     Ages 19+ for Health Departments Only
Vaccine	age <1	age 1	age 2	 ages 3-5	age 6	ages 7-10	ages 11-12	ages 13-18	ages 19-24	ages 25-44	ages 45-64	ages 65+	Total	
DT 1 (ped)						West Virginia Immunization Program
1-800-642-3634
(304) 558-2188
Fax 1-888-558-1941
Enter totals for all rows in the Total column		
DT 2 (ped)								
DT 3 (ped)								
DT 4 (ped)								
Td 1 (adult)														
Td 2 (adult)														
Td 3 (adult)														
Td 4 (adult)														
MMR 1														
MMR 2														
Hib 1														
Hib 2														
Hib 3														
Hib 4														
IPV 1														
IPV 2														
IPV 3														
IPV 4														
DTaP  1														
DTaP  2														
DTaP  3														
DTaP  4														
DTaP  5														

VFC Vaccine Usage Worksheet

Provider Name:		Numbers are required for this report.  Do not send with hash marks/check marks.  

There are separate forms for requesting vaccines and reporting balances on hand, expiration, spoilage and wastage.	
Pin Number:			
Usage from:	Date:	to	Date:		
Contact Name:			
											        Ages 19+ for Health Departments Only
Vaccine	age <1 	age 1	age 2	ages 3-5	age 6	ages  7-10	ages  11-12	ages 13-18	ages 19-24	 ages   25-44	ages 45-64	ages 65+	Total	
Prevnar 1					West Virginia Immunization Program
1-800-642-3634
(304) 558-2188
Fax 1-888-558-1941

Enter totals for ALL rows in the Total column.		
Prevnar 2							
Prevnar 3							
Prevnar 4							
Hep-B-PF 1														
Hep-B-PF 2														
Hep-B-PF 3														
Rotavirus 1														
Rotavirus 2														
Rotavirus 3														
FLU														
FLU-PF														
Pneumococcal														
Varicella 1														
Varicella 2														
Pediarix 1														
Pediarix 2														
Pediarix 3														
Menactra														
Tdap														
Report state supplied MMR vaccine administered to family planning and maternity clients here.	MMR 1									
	MMR 2								

Provider Name:		Numbers are required for this report.  Do not send with hash marks/check marks.  

There are separate forms for requesting vaccines and reporting balances on hand, expiration, spoilage and wastage.	
Pin Number:			
Usage from:	Date:	to	Date:		
Contact Name:			
                                                                                                                             Ages 19+ for Health Departments only
Vaccine	age <1 	age 1	age 2	ages 3-5	age 6	7-8	9-10	ages  11-12	ages 13-18	ages 19-24	 ages   25-44	ages 45-64	ages 65+	Total	
HPV 1															
HPV 2															
HPV 3															
Hepatitis A  1														
Hepatitis A  2														
MMRV
(ProQuad) 1														
MMRV 
(ProQuad) 2														
Pentacel 1														
Pentacel 2														
Pentacel 3														
Pentacel 4														
Kinrix
(4-6 years of age)															
					West Virginia Immunization Program
1-800-642-3634
(304) 558-2188
Fax 1-888-558-1941
       Enter totals for all rows in the Total column.