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Get FL VFC Program 2008

Florida Vaccines for Children VFC Program Vaccine Usage Worksheet PIN Check below the appropriate box for eligibility and vaccines. C VFC Eligibility D Totals E Record the total number of children immunized by age and VFC eligibility Medicaid No Insurance Underinsured American Indian/Alaskan Native TOTAL CHILDREN IMMUNIZED F G H I 1 YEAR 1-6 YEARS 7-10 YEARS 11-12 YEARS 13-18 YEARS Mailing Adrress FL Department of Health Bureau of Immunization 4052 Bald Cypress Way Bin A-11 Tallahassee Florida 32399-1700 Fax 850 245-4734 Phone 1-800-483-2543 Revised September 2008 MMRV Varicella Flu 0. 50mi Flu 0. 25ml Tdap Td Rotavirus PCV-7 Meningococcal HPV Hib Hep B/Hib Hep B Hep A DTaP/Hep B/IPV DTaP Am* Indian/AK Native EIPV Polio Vaccines Shot Date Patient ID B A. C VFC Eligibility D Totals E Record the total number of children immunized by age and VFC eligibility Medicaid No Insurance Underinsured American Indian/Alaskan Native TOTAL CHILDREN IMMUNIZED F G H I 1 YEAR 1-6 YEARS 7-10 YEARS 11-12 YEARS 13-18 YEARS Mailing Adrress FL Department of Health Bureau of Immunization 4052 Bald Cypress Way Bin A-11 Tallahassee Florida 32399-1700 Fax 850 245-4734 Phone 1-800-483-2543 Revised September 2008 MMRV Varicella Flu 0. 50mi Flu 0. 25ml Tdap Td Rotavirus PCV-7 Meningococcal HPV Hib Hep B/Hib Hep B Hep A DTaP/Hep B/IPV DTaP Am* Indian/AK Native EIPV Polio Vaccines Shot Date Patient ID B A..

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