West Virginia Immunization Program
Vaccine Incident Report (VIR)

Providers must report all VFC vaccines last, wasted or expired.  

Please complete the entire form and fax to (304) 558-1941.  Call the Immunization Program at 1-800-642-3634 or locally at (304) 558-2188 to report each incident.

Name and title of person completing form: _____________________________________  
                                                                                                                                 
Date:  ________________________________                                                               

VFC PIN Number:	____________________	                                             

Provider Name :     ____________________________________________________________
            Address: 	___________________________________________________________
                    City: 	________________________   Zip Code: ________________________
Phone Number: 	_____________________    Fax Number: ________________________

Vaccine Information

Indicate type of vaccine(s) and number of doses involved:

	Vaccine:     		  ____________________________________                                                                                       
	Manufacturer:            ____________________________________                                                                        
	Lot Number:      	  ____________________________________                                                                              
	Number of Doses:     ____________________________________                                                                      
Date and Time (approximate of incident): _________________________________                                                                   
Briefly summarize the reason the event occurred and actions taken: ________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________