2017 Minnesota Vaccines for Children (MnVFC) Annual Report of the Number
of Immunized Pediatric Patients
• Submit this annual report each year by Nov. 30. We prefer you submit an online version of this report available on MnVFC Forms (www.
health.state.mn.us/divs/idepc/immunize/mnvfc/forms.html). The paper version of this report can be returned by email or mail. The use
of fax is discouraged.
• Orders may be held until you submit this report. Make sure to complete all pages.
• If you redistribute vaccine to satellite sites, submit one annual report that includes data from those sites.
• If your site submits dose-level eligibility (DLE) information to MIIC, you can collect the count of pediatric patients using the "MnVFC
Report" function in MIIC. See the MnVFC Reports in MIIC user guide on Vaccine Ordering and Management in MIIC (www.health.state.
mn.us/divs/idepc/immunize/registry/hp/ordering.html).
SITE INFORMATION
Date:
Site name:
MnVFC PIN:
Vaccine delivery address:
City:
ZIP:
Individual completing this report:
Phone:
Fax:
SITE TYPE (select the one that best describes your facility)
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Adolescent only provider
Birthing hospital
Community health center
Correctional facility
Drug treatment facility
Family planning
FQHC/RHC (Community/Migrant/Rural)
Juvenile detention center
Migrant health facility
Pharmacy
Private hospital
Private practice (solo/group HMO)
Public health department
Public health department that has signed
a Memorandum of Understanding to serve
underinsured children
 Refugee health facility
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School-based clinic
STD/HIV
Teen health center
Tribal clinic or Indian Health
Services
 WIC
 Other ________________________
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VACCINES OFFERED
 All ACIP recommended vaccines
 Offers select vaccines (this option is only available for facilities designated as specialty providers* by the MnVFC program)
*The MnVFC program has the authority to designate MnVFC providers as specialty providers. Specialty provider is defined as a provider
that only services:
(1) A defined population due to the practice specialty (e.g., OB/GYN, STD clinic, family planning, etc.) or
(2) A specific age group within the general population of children ages birth through 18 years.
(3) At the discretion of the MnVFC program, enrolled providers such as pharmacies and mass vaccinators may offer only influenza vaccine.
Select vaccines offered by specialty provider:
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DTaP
Hepatitis A
Hepatitis B
Hib
HPV
Influenza
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MCV4
MMR
PCV13
PPSV23
Polio
Rotavirus
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Td
Tdap
Varicella
Other __________________________________________
• This report is a count of all patients 0 through 18 years of age that received an immunization between Oct. 1, 2015, and Sept. 30, 2016.
• Count each patient only once for the entire year. For example, an infant may receive multiple immunizations during several visits his/her
first year of life. This infant would be counted only once on this report.
• If you redistribute vaccine to satellite sites, submit one annual report that includes data from those sites.
(9/2016) Page 1 of 2
2017 MnVFC Annual Report of Immunized Pediatric Patients
Patient category
(count each patient only once in the categories listed below)
Younger
than 1 year
1 through 6
years
7 through
18 years
Total
Enrolled in a MN Health Care Program (MA, MnCare, or PMAP) - MnVFC eligible
Uninsured - MnVFC eligible
American Indian or Alaska Native - MnVFC eligible
Underinsured* - MnVFC eligible at LPH, FQHC, RHC, IHS, and tribal health clinics
Insured (private health insurance covers vaccines) - not MnVFC eligible
*Underinsured for this report is defined as:
• Has health insurance that does not cover one or more vaccines, as can be the case with newly licensed vaccines that aren’t yet covered
(MnVFC-eligible for non-covered vaccines only).
• Has health insurance that caps vaccine coverage at a certain amount; once that amount is reached, the person is MnVFC-eligible.
These patients can only be seen at local public health (LPH), Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), Indian
Health Services (IHS), and tribal health clinics.
Note: Children with insurance that does not cover vaccines until a deductible has been met are considered to be fully insured and are not
MnVFC-eligible.
PLEASE RETURN THIS FORM BY EMAIL OR MAIL TO:
Email: [email protected]
Minnesota Department of Health
MnVFC Program
P.O. Box 64975
St. Paul, Minnesota 55164-0975
(9/2016) Page 2 of 2