Broadcast
FAX
DATE:
February 11, 2015
TO:
MnVFC Providers
FROM:
MnVFC Program
RE:
2015-16 MnVFC pediatric flu vaccine orders due by noon on Feb. 20
Please route to:
• Clinical supervisor
• Medical director
• Clinic manager
• Clinic staff
• Pharmacy
• Vaccine staff
If you have already submitted your order, please disregard this message.
2015-16 MnVFC pediatric influenza vaccine orders are due by noon on Friday, Feb. 20, 2015. As in years past,
the MnVFC program only provides influenza vaccine for eligible children 18 years of age and younger.
How to Order Influenza Vaccine
•
Online: www.health.state.mn.us/vfc and go to MnVFC Announcements. Look for the online link with
this broadcast fax posting.
•
Paper: use the attached 2015-16 MnVFC Pediatric Influenza Vaccine Order Form and return by email,
fax, or mail.
•
Do not do both or you may receive double the amount of vaccine you really need!
•
We will let you know when you can expect to receive your influenza vaccine.
•
Not ordering influenza vaccine? Submit an order form even if you are not ordering influenza vaccine,
you can do this by:
o Online: Selecting “No” to the first question, which asks, “Would you like to prebook MnVFC
influenza vaccine for the 2015-16 season?”
o Paper: Placing an X in the box next to “No, I do not wish to prebook MnVFC influenza vaccine
for the 2015-16 season.”
If you have questions, call the MnVFC program at 651-201-5522 or 1-800-657-3970.
Attachment: 2015-16 MnVFC Pediatric Influenza Vaccine Order Form
Vaccine Preventable Disease Section
625 N Robert Street * P.O. Box 64975 * St Paul, Minnesota 55164-0975
www.health.state.mn.us/vfc
M n V F C P R O G R AM : 6 51 - 2 0 1 - 55 2 2 o r 8 0 0 - 6 5 7 - 3 9 7 0
2015-16 MnVFC Pediatric Influenza Vaccine Order Form
Even if you are not ordering MnVFC influenza vaccine — complete and submit this form online at https://survey.vovici.com/se.ashx?s=56206EE35D26ED44 by
February 20, 2015. You can also submit it via email to [email protected], fax it to 651-201-5501, or mail it to the address below. Please note this is your only
opportunity to request MnVFC influenza vaccine. Delivery information will be sent when it becomes available.
Check here if new address
No, I do not wish to prebook MnVFC influenza vaccine for the 2015-16 season.
Date:
Clinic name:
Delivery address (no PO boxes):
Contact name:
MnVFC PIN:
ZIP code:
City:
Email address:
Telephone number:
Delivery instructions:
Do not deliver on these days and times:
Type
Influenza vaccine
Age indications
6 months through 35 months ONLY
Inactivated injectable
Inactivated injectable
Fluzone Quadrivalent
0.25ml
Doses
ordered
Packaging
10 pre-filled syringes
0.5ml
6 months and older
0.5ml
1 multi-dose vial of 10 doses
Fluarix Quadrivalent
(GSK)
36 months and older
0.5ml
10 pre-filled syringes
FluLaval Quadrivalent
36 months and older
0.5ml
1 multi-dose vial of 10 doses
FluMist Quadrivalent
Healthy children age 2 years and older
0.2ml
10 single-dose sprayers
(MedImmune)
Preservative-free or
thimerosal-free*
10 pre-filled syringes
36 months and older
(sanofi pastuer)
(GSK)
Live-attenuated intranasal
Dose
Do you have expired or spoiled
MnVFC vaccine?
All nonviable MnVFC vaccine (expired
or spoiled) must be returned to
McKesson. If you have expired and
unused MnVFC influenza vaccine,
please fax the Returning Nonviable
MDH Vaccine form to 651-201-5501
and MDH will contact McKesson to
coordinate a UPS pick-up within one to
two weeks.
Thimerosal-free,
preservative-free
10 single-dose vials
Contains thimerosal
preservative
Thimerosal-free,
preservative-free
Contains thimerosal
preservative
Thimerosal-free,
preservative-free
* All MDH influenza vaccine products are thimerosal-free except one. Be sure to order enough thimerosal-free vaccine to provide it for parents requesting it.
If you prefer to receive a different brand of flu vaccine than is listed on the order form, please send an email to [email protected].
This order form must be signed by a licensed practitioner who is authorized to procure vaccine/biologicals according to Minnesota Statutes, Section 151.37 (e.g., M.D.,
D.O., nurse practitioner, physician’s assistant, or pharmacist). Please include the individual’s title.
Name and title (M.D., D.O., N.P., P.A., or R.Ph. only) ______________________________________________________________________________
 By checking this box, I attest that the completed order form is accurate and that I am a licensed practitioner who is authorized to procure vaccines/biologicals
according to Minnesota Statutes.
 By checking the box, I attest that I have the authority to complete this vaccine order form on behalf of the "Prescribing Professional" on this form whose signature is on
file at our site as required by state law.
MnVFC Program
P.O. Box 64975
St. Paul, MN 55164-0975
651-201-5522, 1-800-657-3970
www.health.state.mn.us/vfc
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