North Dakota H1N1 Vaccination Site Registration

This form will be used to estimate the number of H1N1 doses needed by each site and to obtain shipping information. Consider this form a pre-book form for H1N1 influenza vaccine. Vaccine will be distributed to providers based on the estimates provided on this form. In order to prevent duplication, one form should be completed for each site where vaccine is being administered.

Please ensure that a Vaccine Provider Agreement has been completed for your clinic and communicate with clinics if this form is being completed on their behalf (i.e., a hospital completes a form for each satellite clinic).

Vaccination site information

Is your facility enrolled in the North Dakota Prevention Partnership Program (providers who currently receive state-supplied vaccine)?

If yes, what is your  provider number?

Is your facility enrolled in the North Dakota Immunization Information System (NDIIS), the State's immunization registry?


Contact information
Facility name:
Address: (location where vaccine will be administered):
City: State:      Zip:
County:
Primary point of contact (must work on-site at the facility)
Name:
Phone: Fax:
Email:
 
Medical Director (The chief physician or medical director who signs standing orders for immunizations)
Name:
Medical license number:
Phone: Fax:
Email: (business only)

 

How would you describe your facility? (check all that apply)

,   please specify:
,  please specify:

In order to prevent duplication, please include the number of individuals, not doses, that you plan on vaccinating at your site. This form should be completed separately for all clinics administering the 2009 Influenza A (H1N1) Monovalent Vaccine.

Please provide an estimate of the number of individuals your site will administer vaccine to in each of the following populations:

 6 months to 1 year old  
 1 year through 4 years old  
 5 years through 18 years old  
 19 years through 24 years old  
 25 years through 64 years old with a chronic health condition or household contacts and caregivers of children younger than 6 months of age  
 25 years through 64 years old and healthy  
 65 years and older  
 Residents of long-term care facilities  
 Currently pregnant women  
 Healthcare Workers  

Approximately how many doses of seasonal influenza vaccine did your site administer in the 2008-2009 influenza season?

 

Do you feel that storage (adequate refrigeration) will be an issue at your site? (This will be above and beyond what is necessary for seasonal influenza vaccine storage).

Optional: List up to three additional persons designated to receive email copies of North Dakota communications concerning pandemic influenza vaccine planning at your facility.

Email 1:
Email 2:
Email 3:


Shipping information

Facility shipping informationn
(The physical location that vaccine will be shipped to - if your site is within a healthcare system that orders vaccine for several sites through a central location please enter the address of the central location).

North Dakota Prevention Partnership Provider Number of shipping site:
Shipping address: (no P.O. boxes)   
City: State:   Zip:
County:
Shipping contact person
(If your system orders vaccine for several sites through a central location please enter contact information for the person who will be managing the ordering and receipt of H1N1 vaccine at the central location.)
Name:
Phone: Fax:
Email: (business only)

Shipping instructions
(Days and hours facility is staffed to receive shipments.)
Hours Monday Tuesday Wednesday Thursday Friday
8 am - Noon
Noon - 5 pm