Get Tdap Cocoon Program Vaccine Order Form - Ct.gov - Ct

Filling out the Tdap Cocoon Program Vaccine Order Form is essential for community health centers to request free Tdap vaccines for eligible individuals. This guide provides a clear, step-by-step approach to help users complete the form accurately and efficiently.

Follow the steps to complete the Tdap Cocoon Program Vaccine Order Form.

1. Press the ‘Get Form’ button to access the Vaccine Order Form and view it in your preferred document format.
2. In the ‘Date of Order’ field, enter the current date when you are submitting the order form.
3. Provide the name of the facility that is placing the order in the ‘Name of Facility’ section.
4. Fill in the ‘ZIP’ code corresponding to the facility's shipping address.
5. Complete the ‘Shipping Address’ field with the complete address where the vaccines will be sent.
6. Indicate the ‘City’ accompanying the shipping address for accurate delivery.
7. Enter a valid ‘Phone’ number for contact purposes, ensuring it's accessible.
8. Fill in the ‘Contact Name’ of the individual responsible for the order.
9. In the ‘Order Portion’ section, indicate the quantity of doses per pack you want to order under ‘Doses per pack.’
10. State the total number of ‘Doses Ordered’ needed for your facility.
11. Document the number of ‘Doses on Hand’ to provide context on inventory.
12. Specify the ‘Expiration Date(s)’ for the vaccine doses being ordered.
13. Enter your facility’s ‘PIN’ number, which is a four-digit code required for order verification.
14. Use the ‘Comments’ section to note any additional information relevant to your order.
15. Complete the Dose Administered Portion, specifying the ‘Doses Used’ since the last order and filling in the number of live births for birth hospitals.
16. Indicate the approximate number of postpartum individuals, pregnant women, infant contacts, hospital health care workers, and total doses in their respective fields.
17. Once you have filled all sections, save your changes, download the form, print it for your records, or share it as needed.

Complete the Tdap Cocoon Program Vaccine Order Form online to ensure timely vaccination and protect infants.