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