Forms
COVID-19 Vaccine Consent Form Spanish
Immunization - Form
December 18, 2020
This form should be used as Consent for COVID-19 Vaccinations
VFC COVID-19 Troubleshooting Record Form
Immunization - Form
December 15, 2020
This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.
VFC Northeast Region Temperature Log Form
Immunization - Form
June 29, 2020
Colfax, Guadalupe, Harding, Los Alamos, Mora, Rio Arriba, San Miguel, Santa Fe, Taos, and Union
VFC Northwest Region Temperature Log Form
Immunization - Form
June 29, 2020
Cibola, McKinley, San Juan, Sandoval, Torrance, and Valencia
VFC Southeast (A) Region Temperature Log Form
Immunization - Form
June 29, 2020
Chaves, Curry, DeBaca, Lincoln, and Quay
VFC Southeast (B) Region Temperature Log Form
Immunization - Form
June 29, 2020
Eddy, Lea, Lincoln, and Roosevelt
VFC Southwest Region Temperature Log Form
Immunization - Form
June 29, 2020
Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro
Certificate of Exemption from Immunization (English)
Immunization - Form
April 14, 2020
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
Certificate of Exemption from Immunization (Spanish)
Immunization - Form
April 14, 2020
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
VFC Transport Temperature Log Form for Refrigerated Vaccines
Immunization - Form
February 14, 2020
Complete this log when transporting vaccines to an alternate or back-up refrigerator, or when transferring to another provider.