Forms and Publications - Adult Safety Net Program


Reporting Vaccine Services to UNinsured Female Veterans


 

Printed copies of Adult Safety Net publications may be ordered and shipped to your location at no charge to you via the Immunization Unit Online Order Form.


Vaccine Inventory, Storage and Reporting

Publication # Title Revision Date
11-16658 Adult Safety Net (ASN) Available Vaccines 07/2022
F11-12842 Adult Safety Net (ASN) Patient Eligibility Screening Form - Bilingual (PDF) 09/2022
Online Form Provider Agreement Form NA
11-13602 2023 TVFC and ASN Provider Manual 9/2022 
C-88 Combined Tally and Physical Inventory (XLS) 02/2012
E11-14498 Vaccine Management Plan Templates 02/2022
EC-67 Vaccine Transfer Authorization Form (PDF) 05/2022
EC-105-FC Temperature Recording Form (Freezer-Celsius) (PDF) 09/2020
EC-105-FF Temperature Recording Form (Freezer - Fahrenheit) (PDF) 09/2020
EC-105-RC Temperature Recording Form (Refrigerator-Celsius) (PDF) 09/2020 
EC-105-RF Temperature Recording Form (Refrigerator-Fahrenheit) (PDF) 09/2020 
EF11-14171 Vaccine Borrowing Form (PDF) 06/2022 


Patient Eligibility/Referral

Publication # Title Revision Date
EF11-13788 Patient Referral Form for Vaccination From Local Health Department or Public Health Clinic (PDF)   08/2016

Provider Enrollment and Withdrawal

Publication # Title Revision Date
F11-11443  Provider Withdrawal Form (PDF)  04/2022 
11-15016 New Enrollment Checklist  03/2022
11-15224 Changes to Enrollment Form (PDF) 04/2022

ASN Promotional Materials

Publication # Title Revision Date
11-14202 “Adults Need Vaccine Too” Adult Safety Net (ASN) Program Brochure - English (PDF) 05/2022
11-16672 Adult Safety Net (ASN) Program Provider Flyer - English (PDF) 08/2022


Adult Site Visit Reviewer Guide

The reviewer guide below will be used to conduct site visits to healthcare providers enrolled in the Adult Safety Net Program and for special projects with healthcare providers providing immunization services to adults. 

2022 Adult Site Visit Reviewer Tool

ASN Compliance Site Visit Acknowledgement of Receipt (PDF)- This form is to be used for sites with PINs

ASN Follow-Up Plan


Adult Immunization Standards, Schedules, & Recommendations

The following resources are based on recommendations from the Advisory Committee on Immunization Practices (ACIP) and/or the National Vaccine Advisory Committee (NVAC).

Note: All adult health-care providers (including ASN Program providers, non-ASN Program adult immunization providers, and even non-immunizing adult providers) should refer to the Centers for Disease Control and Preparedness (CDC) Standards for Adult Immunization Practice.