Washington State DOH Immunization Program

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Vaccine Accountability: ■ Make immunization records available to the local health jurisdiction and the state Department of Health Immunization Program (if requested). ■ Participate in a site visit by the local health jurisdiction or state Department of Health, which may include an immunization assessment (AFIX). ■ Provide data on the number, age and VFC status of children seen in the practice by completing the annual data request for the provider profile. ■ Complete a provider satisfaction survey (if requested). ■ Complete the Private Provider's Report of Vaccine Usage form provided by the local health jurisdiction, which includes: the doses of vaccine administered by vaccine type and age group of each patient; doses of vaccine wasted, lost or expired; inventory of vaccine by vaccine type and number of doses. Vaccine Security and Equipment Maintenance • Post "Do Not Disconnect" signs at both the electrical outlet where your storage unit is plugged in and the circuit breaker to prevent storage units losing power. By signing this form, I certify on behalf of myself and all immunization providers in this facility, I have read and agree to the Vaccines for Children enrollment requirements listed above and understand I am accountable (and each listed provider is individually accountable) for compliance with these requirements. Medical Director or Equivalent Name (print). Signature Name (print) Second individual as needed: Signature: Date Date: DOH 348-022 revised for 2016 If you have a disability and need this document in a different format, please call 1-800- 525-0127 (TDD/TTY 1-800-833-6388).