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CDC Supplemental COVID-19 Vaccine Redistribution Agreement

WEBThe parties to this agreement are CDC and healthcare organizations, third-party vendors, and vaccination providers that redistribute COVID-19 vaccine. CDC cannot reimburse …

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Authorization For Release Of Immunization Records

WEBDepartment of Health. Authorization For Release Of Immunization Records. Introduction: I hereby authorize the Pennsylvania Department of Health to release information/records …

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CDC COVID-19 Vaccination Program Provider Agreement A and B

WEBPlease complete Sections A and B of this form as follows: The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) …

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Immunization Materials · Starter Portal

WEBPlease direct questions specific to PA Immunization Materials ordering to: [email protected]. Full Name. Organization. Address Line One. Address Line …

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Environmental Health Concern Form · Starter Portal

WEBEnvironmental Health Concern Form. The Division of Environmental Health Epidemiology can assist with relevant environmental health concerns. Please provide your name and …

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Speaking Request Form · Starter Portal

WEBThe Pennsylvania Department of Health (DOH) is in receipt of your request for a representative of the Department to participate in your conference/meeting. Please note …

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Project Firstline Training Request · Starter Portal

WEBPennsylvania Project Firstline (PA PFL) Training Request Form. Please complete all the fields below to indicate the type of training that your facility is seeking from PA PFL. …

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Occupancy Request Form · Starter Portal

WEBZip Code. County. List All Drawing Index Numbers Associated with this project below. Inspection Request From Date MM/DD/YYYY. Inspection Request To Date …

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Contact Us Form · Starter Portal

WEBContact Us Form. Please provide your contact information. Required fields are marked with an asterisk (*). Select the most appropriate category for your inquiry from the list below: …

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eVitals Facility Registration Form · Starter Portal

WEBFacility Information. Facility name as currently displayed in DAVE/EDRS. Facility's Licensed Name. Doing Business As (DBA) Facility Name. How facility name should be displayed …

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Act 96 Customer Form · Starter Portal

WEBAct 96 of 2018 Temporary Exemption Form. Act 96 – Electronic Prescribing. Do you prescribe controlled substances *

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VFC Program Policies and Guidelines Acknowledgment Form

WEBThe 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 …

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C. Auris Poster Order Form · Starter Portal

WEBC. Auris Poster Order Form. E-mail. Name. Professional Role. *. Phone Number. Name of PA Healthcare Facility Requesting materials. Shipping Address. Type of PA Healthcare …

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Feedback Form · Starter Portal

WEBPlease share your email address if you'd like someone to reach out and discuss your comments. **. Generate a new image Play the audio code. Enter the code from the image.

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