Free None - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 42000 (Rev. 09/02)

STATE OF WISCONSIN Telephone (608) 267-5148 Fax (608) 267-9493

VACCINE ORDER
INSTRUCTIONS Order the number of doses (not vials) of vaccine that are needed. If Vaccine Information Statements are needed, indicate the quantity in the appropriate space below. The vaccine order should be for a 2-month supply. Allow 2 weeks for delivery. Sign and return completed order to the address below or Fax. (Note: A public provider is a health department, tribal clinic or Federally Qualified Health Center.) Public and Private Providers Vaccine Doses Requested Td (Adult) IPV MMR Hep B - Hib (Merck &
Company) (Comvax)

Name of Agency Requesting Vaccine(s) Street Address City State Zip

PIN No.

Vaccine

Private Providers Only Doses Requested

DTaP (GSK ­ Infanrix ) DTaP (Aventis Pasteur-Tripedia) DTaP (Aventis -DAPTACEL) Hep B
(GSK-ENGERIX-B 0-18 years)

DT (Pediatric) Varicella Hep B ­ Adult Pneumococcal: Conjugate (PCV7) Limited quantity**

Hep B (Merck & Company) ­
Recombivax HB 0-18 years)

Hib (Merck & Company) PedvaxHIB ) Hib (Wyeth ­ HibTITER) Hib (Aventis Pasteur­ ActHIB)

Vaccine

Public Providers Only Doses Requested

Vaccine Information Statements Indicate the quantity forms needed. Do not indicate by marking with a check ( ) mark. Forms are packaged 100 forms per pad. DTaP __________ Hib __________ Td Polio __________ __________

DTaP (GSK-Infanrix)

Hep B
(GSK-ENGERIX-B 0-18 years)

MMR __________ Hep B __________

Varicella __________

Hib (Merck & Company)
PedvaxHIB)

Pneumococcal: Conjugate________ Vaccine Administration Record (Signature form)

__________

SIGNATURE ­ Person Completing this order

Telephone ( )

FAX: ( )

Date Signed

Return completed form to:

Wisconsin Immunization Program Bureau of Communicable Diseases P. O. Box 2659 Madison, WI 53701-2659 **Indicate the # of doses of Prevnar you currently Fax (608) 267-9493 have on hand at this time___________________