Forms
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 17, 2022
This form allows you to provide immunization information for entry into NMSIIS.
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Adult Vaccine Consent Form
Immunization - Form
October 1, 2021
This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.
Got Shots Fillable Form
Immunization - Form
July 1, 2021
Got Shots Fillable Form
Got Shots? Fillable Form - Eng
Got Shots? Fillable Form - Esp
COVID-19 Vaccine Consent Form English
Immunization - Form
March 25, 2021
This form should be used as Consent for COVID-19 Vaccinations
COVID-19 Vaccine Consent Form Spanish.
Immunization - Form
February 25, 2021
This form should be used as Consent for COVID-19 Vaccinations
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 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 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.
School Consent to Enter Student Records into NMSIIS
Immunization - Form
September 17, 2018
This is a customizable form for use by schools to collect consent from parents so students' historic immunization records may be added to NMSIIS.
VFC Approved School Sites - Needle, Syringe, & e-kit Order Form
Immunization - Form
February 23, 2018
This form is to be used for needles/syringes, and e-kit medications and is for Vaccines for Children Approved Sites Only.
VFC Middle School Vaccination Letter/Permission Form
Immunization - Form
February 23, 2018
This is the letter addressed to parents or legal guardians to determine whether or not a child is to be vaccinated at school. This letter is to be sent out with the VFC school immunization consent form.
VFC Middle School Vaccination Letter/Permission Form (Spanish)