Approver Comments:
Status:
PENDING PROVIDER SUBMISSION
VFC PIN:
Organization Name:
Facility Name:
Agreement Signatory:
Agreement Signatory Title:
Is Information Sharing Agreement current?
Yes
No
Last Renewed:
--select--
2024
2023
2022
Facility Address:
Street Address:
Street Address2:
City:
State:
--select--
U.S. Armed Forces - Americas
U.S. Armed Forces - Europe
U.S. Armed Forces - Pacific
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
County:
--select--
ANDERSON
BEDFORD
BENTON
BLEDSOE
BLOUNT
BRADLEY
CAMPBELL
CANNON
CARROLL
CARTER
CHEATHAM
CHESTER
CLAIBORNE
CLAY
COCKE
COFFEE
CROCKETT
CUMBERLAND
DAVIDSON
DECATUR
DEKALB
DICKSON
DYER
FAYETTE
FENTRESS
FRANKLIN
GIBSON
GILES
GRAINGER
GREENE
GRUNDY
HAMBLEN
HAMILTON
HANCOCK
HARDEMAN
HARDIN
HAWKINS
HAYWOOD
HENDERSON
HENRY
HICKMAN
HOUSTON
HUMPHREYS
JACKSON
JEFFERSON
JOHNSON
KNOX
LAKE
LAUDERDALE
LAWRENCE
LEWIS
LINCOLN
LOUDON
MCMINN
MCNAIRY
MACON
MADISON
MARION
MARSHALL
MAURY
MEIGS
MONROE
MONTGOMERY
MOORE
MORGAN
OBION
OVERTON
PERRY
PICKETT
POLK
PUTNAM
RHEA
ROANE
ROBERTSON
RUTHERFORD
SCOTT
SEQUATCHIE
SEVIER
SHELBY
SMITH
STEWART
SULLIVAN
SUMNER
TIPTON
TROUSDALE
UNICOI
UNION
VAN BUREN
WARREN
WASHINGTON
WAYNE
WEAKLEY
WHITE
WILLIAMSON
WILSON
Zip Code:
Vaccine Delivery Address:
Check if vaccine delivery address is the same as facility address:
Street Address:
Street Address2:
City:
State:
--select--
U.S. Armed Forces - Americas
U.S. Armed Forces - Europe
U.S. Armed Forces - Pacific
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
County:
--select--
ANDERSON
BEDFORD
BENTON
BLEDSOE
BLOUNT
BRADLEY
CAMPBELL
CANNON
CARROLL
CARTER
CHEATHAM
CHESTER
CLAIBORNE
CLAY
COCKE
COFFEE
CROCKETT
CUMBERLAND
DAVIDSON
DECATUR
DEKALB
DICKSON
DYER
FAYETTE
FENTRESS
FRANKLIN
GIBSON
GILES
GRAINGER
GREENE
GRUNDY
HAMBLEN
HAMILTON
HANCOCK
HARDEMAN
HARDIN
HAWKINS
HAYWOOD
HENDERSON
HENRY
HICKMAN
HOUSTON
HUMPHREYS
JACKSON
JEFFERSON
JOHNSON
KNOX
LAKE
LAUDERDALE
LAWRENCE
LEWIS
LINCOLN
LOUDON
MCMINN
MCNAIRY
MACON
MADISON
MARION
MARSHALL
MAURY
MEIGS
MONROE
MONTGOMERY
MOORE
MORGAN
OBION
OVERTON
PERRY
PICKETT
POLK
PUTNAM
RHEA
ROANE
ROBERTSON
RUTHERFORD
SCOTT
SEQUATCHIE
SEVIER
SHELBY
SMITH
STEWART
SULLIVAN
SUMNER
TIPTON
TROUSDALE
UNICOI
UNION
VAN BUREN
WARREN
WASHINGTON
WAYNE
WEAKLEY
WHITE
WILLIAMSON
WILSON
Zip Code:
Mailing Address:
Check if mailing address is the same as facility address:
Street Address:
Street Address2:
City:
State:
--select--
U.S. Armed Forces - Americas
U.S. Armed Forces - Europe
U.S. Armed Forces - Pacific
ALABAMA
ALASKA
AMERICAN SAMOA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
NORTHERN MARIANA ISLANDS
OHIO
OKLAHOMA
OREGON
PALAU
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
County:
--select--
ANDERSON
BEDFORD
BENTON
BLEDSOE
BLOUNT
BRADLEY
CAMPBELL
CANNON
CARROLL
CARTER
CHEATHAM
CHESTER
CLAIBORNE
CLAY
COCKE
COFFEE
CROCKETT
CUMBERLAND
DAVIDSON
DECATUR
DEKALB
DICKSON
DYER
FAYETTE
FENTRESS
FRANKLIN
GIBSON
GILES
GRAINGER
GREENE
GRUNDY
HAMBLEN
HAMILTON
HANCOCK
HARDEMAN
HARDIN
HAWKINS
HAYWOOD
HENDERSON
HENRY
HICKMAN
HOUSTON
HUMPHREYS
JACKSON
JEFFERSON
JOHNSON
KNOX
LAKE
LAUDERDALE
LAWRENCE
LEWIS
LINCOLN
LOUDON
MCMINN
MCNAIRY
MACON
MADISON
MARION
MARSHALL
MAURY
MEIGS
MONROE
MONTGOMERY
MOORE
MORGAN
OBION
OVERTON
PERRY
PICKETT
POLK
PUTNAM
RHEA
ROANE
ROBERTSON
RUTHERFORD
SCOTT
SEQUATCHIE
SEVIER
SHELBY
SMITH
STEWART
SULLIVAN
SUMNER
TIPTON
TROUSDALE
UNICOI
UNION
VAN BUREN
WARREN
WASHINGTON
WAYNE
WEAKLEY
WHITE
WILLIAMSON
WILSON
Zip Code:
Contact Details:
Type1:
--select--
Agreement Signatory (medical director or equivalent)
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Facility
Contact First Name1,
Middle Initial 1,
and Last Name 1:
Phone Number1:
Phone Number Extension1:
Fax Number1:
Email Address1:
Completed Annual Training1:
Yes
No
Type Of Training Received1:
--select--
2023 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2023 Compliance Site Visit
2023 On-Site Provider Education
2024 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2024 Compliance Site Visit
2024 On-Site Provider Education
2024 VPDIP - IMM EXPO
Type2:
--select--
Agreement Signatory (medical director or equivalent)
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Facility
Contact First Name2,
Middle Initial 2,
and Last Name 2:
Phone Number2:
Phone Number Extension2:
Fax Number2:
Email Address2:
Completed Annual Training2:
Yes
No
Type Of Training Received2:
--select--
2023 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2023 Compliance Site Visit
2023 On-Site Provider Education
2024 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2024 Compliance Site Visit
2024 On-Site Provider Education
2024 VPDIP - IMM EXPO
Type3:
--select--
Agreement Signatory (medical director or equivalent)
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Facility
Contact First Name3,
Middle Initial 3,
and Last Name 3:
Phone Number3:
Phone Number Extension3:
Fax Number3:
Email Address3:
Completed Annual Training3:
Yes
No
Type Of Training Received3:
--select--
2023 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2023 Compliance Site Visit
2023 On-Site Provider Education
2024 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2024 Compliance Site Visit
2024 On-Site Provider Education
2024 VPDIP - IMM EXPO
Type4:
--select--
Agreement Signatory (medical director or equivalent)
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Facility
Contact First Name4,
Middle Initial 4,
and Last Name 4:
Phone Number4:
Phone Number Extension4:
Fax Number4:
Email Address4:
Completed Annual Training4:
Yes
No
Type Of Training Received4:
--select--
2023 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2023 Compliance Site Visit
2023 On-Site Provider Education
2024 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2024 Compliance Site Visit
2024 On-Site Provider Education
2024 VPDIP - IMM EXPO
Type5:
--select--
Agreement Signatory (medical director or equivalent)
Primary Vaccine Coordinator
Back-up Vaccine Coordinator
Facility
Contact First Name5,
Middle Initial 5,
and Last Name 5:
Phone Number5:
Phone Number Extension5:
Fax Number5:
Email Address5:
Completed Annual Training5:
Yes
No
Type Of Training Received5:
--select--
2023 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2023 Compliance Site Visit
2023 On-Site Provider Education
2024 CDC "You Call the Shots" (training modules 10 &16) https://www.cdc.gov/vaccines/ed/youcalltheshots.html
2024 Compliance Site Visit
2024 On-Site Provider Education
2024 VPDIP - IMM EXPO