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1 STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH Donald E. Williamson, MD State Health Officer September 30, 2005 Dear Vaccines for Children (VFC) Provider: SUBJECT: Annual VFC Benchmark Data Is Due New VFC Vaccine Order Form Benchmarking is a federal requirement and must be conducted annually by all VFC providers. There are no exceptions. Your benchmarking data is particularly important because it will provide the Alabama VFC Program with a more accurate assessment of your vaccine needs. For example, benchmarking data is the primary method for determining how limited available doses of new vaccines, such as the new meningococcal conjugate vaccine (MCV 4) and the new tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) should be allocated for your practice. On November through November ~ou should log vaccinations given to ALL children 0-18 ~ears of age. Enclosed are copies of the annual benchmark form and instructions. Please submit your benchmark data to the Alabama VFC Program via fax or mail as soon as it is completed. Also enclosed is the new VFC Vaccine Order Form. Please replace the old form with the new form. Effective immediately, you may begin using the new form to order all VFC vaccines for your VFC-eligible patients. Please call if you have any questions. Thank you for your participation in the Alabama VFC Program. Sincerely, Enclosures (3) ~~-o.., :...; C. (=~~-o--"'~...q J Melanie C. Lagarde, R.N., M.P.H., C.H.E.S. Administration and VFC Branch Director Immunization Division, Bureau of Communicable Disease Imcl The RSA Tower. 201 Monroe Street. Montgomery, AL P.O. Box Mont2omerv, AL

2 Helpful Hints for Completing the Annual VFC Provider Benchmark Log Form Updated 9/30/05 Please read the following helpful hints to ensure an accurate vaccine account. Thank you in advance for your time and attention. 1. Submit the benchmark log form only for the period November 1 st through November 30 th. No other months are required, unless the VFC Program has instructed your practice specifically. Benchmark logging should begin on November 1 st and end on November 30 th. The month of November was chosen because this will allow the VFC Program to more accurately determine your influenza vaccine needs. If your practice is closed during part of November or some other situation arises that requires your practice to adjust the time frame, please at least log for a total of 4 weeks beginning on or near November 1 st. In this case, please write the dates that you conducted your benchmark at the top of the form. 2. Complete all information in the demographic box, which includes the practice name, address, zip code, phone number, fax number, and contact person. Please use the practice name that was used to enroll in the VFC Program. 3. Log all requested information on ALL children (VFC and non-vfc) 0-18 years of age. If any element (i.e., vaccine, American Indian/Alaskan Native, insurance category and age) is missing we will not count that visit. This information is required by the Centers for Disease Control and Prevention (CDC). 4. To ensure an accurate count, please note the following: Comvax should be checked as Hib and Hep B. $ Pediarix should be checked as DTaP, Hep B and IPV. $ Prevnar should be checked as PCV and PPV is the high-risk pneumococcal polysaccharide vaccine. $ Menactra should be checked as MCV4. $ Boostrix or Adacel should be checked as Tdap. $ TIV is trivalent inactivated influenza vaccine and should be administered to persons 6 months of age and older. $ LAIV is live attenuated influenza vaccine (FluMist) and should be administered to healthy persons 5-49 years of age. $ Adult Td vaccine should be administered to children 7 through 18 years of age. $ Tdap vaccine should be administered to children 11, 12, & 15 years of age and those entering college for the first time and living in dormitories. $ Pediatric DT should be administered to children through age 6 years of age who have a valid contraindication to pertussis vaccine. $ Please do not add brand names to the form. $ All private insurance should be logged as I. Do not add private insurance names. 4. Use only the current benchmark log form ADPH-IMM-510, Revised 9/30/05. If your practice has an internal computer report or data collection form, please notify Dell Ross at before November for approval.

3 5. If you submit more than one benchmark log form, please complete the page number and the total number of pages located in the bottom right-hand corner. We want to make sure that all of the vaccine that your practice administered is counted. 6. If your practice has more than one physician, submit benchmark log forms for all physicians together. Each physician s staff may log separately, but to avoid confusion or duplication please send all benchmark log forms in together.

4 Annual VFC Provider Benchmark Log Form Period: November 1 through November 30 FROM: Practice Name: Address: Zip code: Phone ( ) Fax ( ) Contact: RETURN BY FAX OR MAIL AFTER NOVEMBER 30 TO: ADPH/IMMUNIZATION Fax: Attn: VFC Phone: P.O. Box Call if Questions Arise Montgomery, AL INSTRUCTIONS: *ALL children (VFC and Non-VFC) and all vaccines (VFC and Non-VFC) should be listed on this log form. If a child is an American Indian or Alaskan Native, check the appropriate space; no insurance category is necessary. Record the insurance category of all the other children using the following abbreviations: **I = Insured; M = Medicaid; N = No Insurance; U = Underinsured. After June 1, 2003, new VFC orders will be filled only after we receive the completed log forms by fax or by mail. Please keep a copy of all completed log forms for your records. Thank you. Record ALL* Children Age 0-18 Years Who Receive Vaccine Example Check the boxes of all antigens/vaccines given in one visit to each child. DT DTaP Hep B Hib IPV MMR PCV Td Tdap VAR MCV4 TIV LAIV PPV Check box if American Indian or Alaskan Native Insurance Category** M Patient Age in Years < ADPH-IMM-510 9/30/2005 (COPY FORM AS NEEDED) page of

5 VACCINE ORDER FORM VFC Provider Name Contact Person Phone # ( ) Fax # ( ) Date Shipping Address Back-up System to Receive Vaccine? Y or N Special Delivery Instructions (days/hours closed): Order ALL vaccines at one time for a 3-month period, and reorder when your clinic is down to a 2-week supply. This will ensure your clinic does not run out of vaccine and that vaccine is used before it expires. If pre-filled syringes or requested vaccine brands are not available, you will receive what is currently available. Vaccine Types Specific Information & Vaccine Brands Current VFC Inventory In Doses Order in Doses ONLY DT DTaP DTaP-HepB-IPV 6 wks 6 yrs of age (Medical contraindication to pertussis vaccine only) 6 wks 6 yrs of age (circle one) Infanrix pre-filled syringes or Infanrix vials or Tripedia or Daptacel 6 wks 6 yrs of age (circle one) Pediarix pre-filled syringes or Pediarix vials DTaP-Hib 4 th Dose ONLY TriHIBit EIPV 6 wks 18 yrs of age IPOL Hep B-PF Birth 18 yrs of age (circle one) Engerix-B pre-filled syringes or Engerix-B vials or Recombivax Hep B/Hib 6 wks 59 mos of age Comvax Hib Meningococcal conjugate (MCV4) 6 wks 59 mos of age (circle one) ActHib or Hibtiter or Pedvax 11 yrs, 12 yrs, 15 yrs of age, and new college freshman up to 18 yrs if age who live in dormitories Menactra MMR with diluent 1 yr 18 yrs of age M-M-R II Pneu 7 conjugate (PCV) 6 wks 23 mos of age and high-risk 24 mos 59 mos of age Prevnar Pneu 23 (PPV) Polysaccharide 2 yrs 18 yrs of age high-risk only Pneumovax 23 Td 7 yrs 18 yrs of age Decavac pre-filled syringes only Tdap Varivax (shipped separately) yrs of age Boostrix pre-filled syringes or Boostrix vials or Adacel 1 yr 18 yrs of age Varivax Fax: Mail: Attention: Dell Ross, ADPH/IMM/VFC Phone: P.O. Box , Montgomery, AL ADPH-IMM-502, Rev.11/05