Forms & Publications - Texas Vaccines for Children
Table of Contents
TVFC Forms
- Texas Vaccines for Children Provider Manual
- Vaccine Inventory, Storage, and Reporting
- Patient Eligibility / Referral
- Provider Enrollment and Withdrawal
Reporting
Resources and Training
- Vaccine Storage and Handling Resources
- Vaccine Adverse Event Reporting System (VAERS) CDC Website and Submission Form
Manuals and Forms
Texas Vaccine for Children and Adult Safety Net Provider Manual
| Stock Number | Title | Revision Date |
|---|---|---|
| 11-13602 | 2023 TVFC and ASN Provider Manual (PDF) | 9/2022 |
Vaccine Inventory, Storage, and Reporting
| Stock Number | Title | Revision Date |
|---|---|---|
| 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) | 03/2022 |
| 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
| Stock Number | Title | Revision Date |
|---|---|---|
| C-10 | Patient Eligibility Screening Record (Bilingual) (PDF) | 05/2017 |
| EF11-13788 | Patient Referral Form for Vaccination From Local Health Department or Public Health Clinic (PDF) | 08/2016 |
| EF11-13789 | TVFC Patient Screening Decision Tree (PDF) | 12/2011 |
Provider Enrollment and Withdrawal
| Stock Number | 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 |
Resources and Training
Vaccine Storage and Handling Resources
| Stock Number | Title | Revision Date |
|---|---|---|
| E11-13605 | Storage Calculation Tool Instructions (PDF) | 05/2010 |
| EF11-13613 | Storage Calculation Tool (XLS) | 05/2010 |
| E11-14481 | Best Practices Refrigerated Vaccines F/C (PDF) | 07/2019 |
| E11-14482 | Best Practices Frozen Vaccines F/C (PDF) | 07/2019 |
| E11-14484 | Vaccine Temperature Best Practices Fridge F/C (PDF) | 07/2019 |
| E11-14483 | Vaccine Temperature Best Practices Frozen F/C (PDF) | 07/2019 |