Order Form
Minnesota Immunization Information Connection (MIIC) Materials
According to the MIIC Data Use Agreement, organizations that participate in MIIC are responsible for informing their
clients of their MIIC participation. Displaying MIIC materials is one way to fulfill this responsibility.
All materials listed on this form are free of charge. You can order these materials by emailing, mailing, faxing, or calling
in your completed form to the Minnesota Department of Health at the contact information listed below. Find other MIIC
resources on the web at Minnesota Immunization Information Connection (MIIC)
(http://www.health.state.mn.us/divs/idepc/immunize/registry/index.html).
Mail
Minnesota Department of Health
Immunization Program
P.O. Box 64975
St. Paul, MN 55164-0975
[email protected]
Email
Phone
800-657-3970 or
651-201-5503
Fax
651-201-5501
Please enter your organization’s information.
Organization
Address
City
State
Phone
Contact
Zip
Please enter the quantity and language, as appropriate, of each material that you would like to order.
Quantity
Per Unit
Limit
10 easels
per pack
No
Limit
Materials for Public Audience
What is MIIC? Easel
Easel-back display for use in health care settings, schools,
and child cares. Currently available in English.
IC#141-1345
______ easel pack(s)
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Order Form – MIIC Materials
Quantity
Per Unit
25 sheets
per pad
1 poster
Limit
No
Limit
No
Limit
Materials for Public Audience
What is MIIC? Tear-off
Pads with tear-off sheets for easel-back poster. Basic information about
MIIC and electronic immunization records for parents.
______ English pad(s)
______ Spanish pad(s)
ID#141-1346
ID#141-1572
Keeping Track of Vaccinations is Easier with MIIC
Poster for use in health care settings, schools, and child cares.
Currently available in English.
ID#141-1436
______ 11”x17” poster(s)
Comments or
questions:
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