Required fields are marked with an asterisk.(*)

The following is a list of Pennsylvania’s immunization policies and guidelines. Read each policy and acknowledge you’ve read and understood each policy by placing a check mark in the appropriate box. After you have checked all the boxes, please sign below.

Existing VFC providers are required to enter the VFC PIN. New providers must enter TBD in all PIN fields.

By signing this form, I attest that the medical director, primary vaccine coordinator, and back-up vaccine coordinator have read, understand and agree to comply with all VFC related policies, guidelines and procedures.