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) | 03/2023 |
| 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
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.
- Recommended Adult Immunization Schedule, United States
- Summary of Recommendations for Adult Immunization (PDF)
- CDC - Vaccine Recommendations of the ACIP
- CDC - Adult Immunization Schedules: Details for Healthcare Professionals
- CDC - Do You Know Which Adult Vaccines You Might Need? (PDF)
- CDC - Recommended Vaccines Prescription Pad (PDF)