DEPARTMENT OF HEALTH AND SENIOR SERVICES
DIVISION OF EPIDEMIOLOGY, ENVIRONMENTAL AND OCCUPATIONAL HEALTH
PO BOX 369
TRENTON, N.J. 08625-0369
www.nj.gov/health
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TO: New Jersey Vaccines For Children (VFC) Providers
FROM: Steven J. Bors
VFC Program Coordinator
Vaccine Preventable Disease Program
SUBJECT: 2011 Vaccines for Children Re-Enrollment
All child and adult providers must re-enroll in the New Jersey Vaccines for Children Program from July 18, 2011 to August 8, 2011 to remain an active participant in the VFC Program and continue to receive vaccines. Providers who initially enrolled after January 1, 2011 are not required to re-enroll during this period. Please return all completed NJVFC forms via fax to (609) 826-4868 or email them to the Program at
Process for re-enrollment:
Forms are located at the following website: www.njiis.nj.gov
Located on the left side of the homepage, click on “VFC – Vaccines For Children Program”. Select VFC Re-enrollment Forms for Children or VFC Re-enrollment Forms for Adults. Complete all four forms and return them by fax or email. Do not send forms through the postal service since this will slow your re-enrollment process. Information must be entered for all questions or the application will be considered incomplete.
As a reminder, in order to store vaccine from the VFC Program, the Centers for Disease Control and Prevention (CDC) requires sites to maintain a National Institute of Standards and Technology (NIST) certified thermometer. If you have not already provided the VFC Program with your certificate, please include a copy of your NIST certificate with your re-enrollment forms.
Documents to be completed by Pediatric facilities:
ð Provider Profile Form (IMM-26) – This form is used to determine how many children meet the NJVFC eligibility criteria in your practice and where to deliver the vaccines. Many offices over estimate the number of NJVFC eligible children they serve.
ð Provider Enrollment Form (IMM-25) – This form defines the compliance requirements for the NJVFC Program and the lead physician’s acceptance of these requirements. The lead physician’s signature is required.
ð Licensed Medical Providers List (IMM-26A) – Names of physicians, nurse practitioners, physician assistants, and any other person(s) in your facility including certified medical assistants that are licensed to administer vaccines must be listed along with their license and Medicaid numbers.
ð Varicella and MMRV Storage Questionnaire (IMM-33) – This form is used to determine whether an office meets the requirements for storing Varicella and MMRV vaccine. Since both these vaccines are temperature sensitive, the freezer must be kept at 5°F temperature or colder. Dormitory style refrigerators are not acceptable in the NJ VFC/CDC guidelines.
Documents to be completed by Adult facilities:
ð Provider Profile Form (IMM-18) – The provider profile form is used to determine how many adults meet the NJVFC eligibility criteria in your practice and where to deliver the vaccines. Many offices over estimate the number of NJVFC eligible adults they serve.
ð Provider Enrollment Form (IMM-25) – This form defines the compliance requirements for the NJVFC Program and the lead physician’s acceptance of these requirements. The lead physician’s signature is required.
ð Licensed Medical Providers List (IMM-26A) – Names of physicians, nurse practitioners, physician assistants, and any other person(s) in your facility including certified medical assistants that are licensed to administer vaccines must be listed along with their license and Medicaid numbers.
ð Varicella and MMRV Storage Questionnaire (IMM-33) – This form is used to determine whether an office meets the requirements for storing Varicella and MMRV vaccine. Since both these vaccines are temperature sensitive, the freezer must be kept at 5°F temperature or colder. Dormitory style refrigerators are not acceptable by in the NJ VFC/CDC guidelines.
NOTE: Your facility will be notified by email with information on the New Jersey Immunization Information System (NJIIS) and New Jersey Inventory Management and Order Distribution System (IMODS) training. December 31, 2011, begins a mandate that providers who administer vaccines enter the vaccination information into the New Jersey Immunization Information System (NJIIS) within 30 days of administration. December 31, 2011, begins a mandate that providers enter VFC vaccine orders into IMODS.
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