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

Inventory, Storage and Reporting
Publication # Title Revision Date
11-16658Adult Safety Net (ASN) Available Vaccines07/2022
F11-12842 Adult Safety Net (ASN) Patient Eligibility Screening Form - Bilingual (PDF) 09/2022
Online Form
Provider Agreement Form NA
11-13602TVFC and ASN Provider Manual2022 
C-88Combined Tally and Physical Inventory (XLS)02/2012
E11-14498Vaccine Management Plan Templates02/2022
EC-67Vaccine Transfer Authorization Form (PDF)05/2022
EC-105-FCTemperature Recording Form (Freezer-Celsius) (PDF)09/2020
EC-105-FFTemperature Recording Form (Freezer - Fahrenheit) (PDF)09/2020
EC-105-RCTemperature Recording Form (Refrigerator-Celsius) (PDF)09/2020 
EC-105-RFTemperature Recording Form (Refrigerator-Fahrenheit) (PDF)
EF11-14171Vaccine Borrowing Form (PDF)

Patient Eligibility/Referral

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

Provider Enrollment and Withdrawal

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

ASN Promotional Materials

Adult Safety Net Program Forms and Publications
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.
Last updated September 28, 2022