POLICY, ELIGIBILITY & ENROLLMENT
POLICY
WyVIP Policy Packet
Please click on the following link to view the Visual Fraud and Abuse Algorithm
Appendix A - Fraud and Abuse Algorithm
Appendix D - Sample Forms
2009 Site Visit Questionnaire
Materials Request Form 12/11/08
Doses Administered Form (VAC2)
Special Clinic Order Form (VAC3) updated 06/09/09
Vaccine Arrival Report (VAC13)
Current Inventory Form (VAC10)
Vaccine Temperature Log - Celcius (VAC9)
Vaccine Storage Troubleshooting Record
Emergency Plan Example PowerPoint Updated May 5, 2009
Emergency Plan Example PDF Updated May 5, 2009
ENROLLMENT (Includes information on eligibility)
Enrollment forms must be MAILED to the Immunization with original signatures.
Faxed copies are NOT accepted.
Child Program Enrollment Forms
Private Provider, Hospital or Indian Health update February 19, 2009
Public Health Nursing
Rural and Federally Qualified Health Centers
Adult Program Enrollment Forms
Public Health Nursing 03/24/09
Non-Public Health Providers 03/24/09
VACCINE PROGRAM
FORMS
Vaccines Currently Available through WyVIP (VAC1)
Special Clinic Order Form (VAC3)
Special Clinic Doses Administered Form (VAC4)
Flu Doses Administered and Inventory Form (VAC5)
Expired and Wasted Vaccine Return Form (VAC6) updated 01/23/09
Vaccine Transfer Form (VAC7)
Vaccine Brand Preference Form (VAC8)
Flu Special Clinic Order Form (VAC11)
Vaccine Transfer Request (VAC12)
COLD CHAIN AND VACCINE STORAGE AND HANDLING
Policy on Vaccine Storage and Handling and Cold Chain
CDC Recommendations for Storage of Selected Biologicals
Cold Chain
Errors in Vaccine Storage and Handling
Inventory Management
Refrigerator Warning Sticker
Storage and Handling Plans
Vaccine Storage Equipment
Temperature Monitoring
Storage Troubleshooting
Information for Vaccine Personnel
Examples of Refrigerator Features
Vaccine Storage Unit Guidelines
Standalone Vaccine Storage
Combination Vaccine Storage
Managing Vaccine Cold Chain - MMWR, October 2003
Emergency Response Worksheet
Don't Be Guilty - flyer
Checklist for Safe Vaccine Handling and Storage
Maintaining Cold Chain During Transport
CLINICAL PROGRAM
Link To CDC Pink Book
1. Wyoming Nurse Practice Act
2. ACIP General Recommendations on Immunization Practice
3. a. 2009 Immunization Schedule for 0 to 6 years of age
b. 2009 Immunization Schedule for 7 to 18 years of age
c. 2009 Immunization Catch-up Schedule 0 to 18 years of age
d. Screening Questionnaire for Child and Teen Immunization
e. Adolescent Vaccine Needs
f. Too Many Vaccines? What You Should Know
g. Thimerosal Timeline
4. a. 2009 Adult Immunization Schedule
b. Screening Questionnaire for Adults
c. Administering Vaccines to Adults
d. Vaccinations for Adults - You're Never Too Old
e. Handling Adult Reactions
f. Suggested Supplies for Adult Immunization Clinics
5. Vaccines Currently Available in the United States
6. a. Guide to Contraindications
b. Contraindications to Vaccines Chart
c. Contraindications to Vaccines
d. Contraindications Crosswalk
7. a. Vaccine Adverse Event Reporting System (VAERS)
b. Reportable Events Table
8. Manufacturer Contact Information
WyIR (Wyoming Immunization Registry)
WyIR Provider Enrollment Agreement
WyIR Individual User Agreement
WyIR Access Level Form
WyIR and Provider Estimates This document outlines how providers can use the registry to
estimate vaccine needs for their office.