[DC GOVERNMENT] H1N1_Vaccine_Pre−Registration

H1N1 Vaccine Pre−Registration Form

Instructions

On this form, HEALTH CARE PROVIDERS may pre−register to receive H1N1 influenza vaccine when it becomes available through the District of Columbia Department of Health and the Centers for Disease Control and Prevention.

Facilities with multiple locations should submit a separate pre−registration form for EACH vaccination site, unless otherwise approved in advance. Fields with red asterisks are required. You are encouraged to print a copy of this completed form before its submission. Hit the "SUBMIT" button at the end to finish the pre−registration.

Name of site being pre−registered:

Please list alternate site by parent company or subsidary company name

Please select from the list of drop−down options

If you select other above, please specify:

Name of the primary person who is the H1N1 point of contact (POC) for this site *

Name of the alternate person who is the H1N1 point of contact (POC) for this site

Phone Number

Alternate Number

Fax Number

Name of the prescriber (e.g. M.D., D.O. Nurse Practitioners) under whose authority vaccinationsare administered at the site

Medical License Number

Qualifications of the POC: (e.g. M.D.,D.O., R.N.,etc...)

PIN Number, if applicable

How many doses of H1N1 vaccine are estimated to be given at this site?:- Select what applies

Pregnant Women

Healthcare Provider (Including EMS Providers)

Chronic Conditions (Including Immuno−compromised)

Caregivers of ages < 6 months

Ages 7 months −24 yrs

Ages 25 yrs – 64 yrs

Ages Over 65

All others categories

Does your facility have adequate cold chain storage?

Yes

Additional Comments

Copy of this pre−registration form will be emailed to your email address provided!

It is highly recommended that you print a copy of this completed form BEFORE you click on "SUBMIT". You will not be able to print a copy after submission. Retain a copy of this form for your records.

Thank you! To finish this pre−registration, click "SUBMIT". You will be redirected to the DC DOH H1N1 webpage for additional information.

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