H1N1 Immunization Provider Registration 
  Provider Registration
1 . Facility Name
Contact Information:
2 . First Name
3 . Middle Initial
4 . Last Name
5 . Title
Vaccine Delivery and Storage Address:
(NO P.O. Boxes Please)
6 . Street
7 . City
8 . State
9 . Zip Code ( Plus 4)
10 . County
Provider Mailing Address
(only enter if different than above)
11 . Mailing Street
12 . Mailing City
13 . Mailing State
14 . Mailing Zip Code (plus 4)
15 . Email Address
16 . Phone Number--
17 . Fax Number--
  Additional Information
Days/Times when you can receive vaccine deliveries:
1 . MondayYes No 
2 . Monday: If yes, please specify times:
3 . TuesdayYes No 
4 . Tuesday: If yes, please specify times:
5 . WednesdayYes No 
6 . Wednesday: If yes, please specify times
7 . ThursdayYes No 
8 . Thursday: If yes, please specify times
9 . FridayYes No 
10 . Friday: If yes, please specify times
B. Please estimate the number of individuals to be immunized at your practice/clinic for each of the following priority groups:
11 . Pregnant Women
12 . Household and caregiver contacts of children younger than 6 months of age
13 . Health care and emergency medical services personnel
14 . Children from 6 months through 18 years
15 . Persons aged 19-24
16 . Persons aged 25 through 64 years who have medical conditions associated with higher risk for flu-related complications
C. Storage equipment:
17 . Does your facility have vaccine storage equipment that will maintain a consistent temperature of 35 - 46 degrees Fahrenheit?Yes No 
18 . Does your facility have accurate thermometers to monitor temperatures in each refrigeration unit?Yes No 
D. Type of Vaccine Provider
19 . Type of Vaccine Provider
20 . If "Other" type of vaccine provider, please specify:
21 . Practice Specialty
         Health Care Facilities: hospitals, LTCFs, nursing homes, rehab facilities, skilled nursing facilities
         Adults only
         Children only
         Adults and Children
         First Responders, EMS Workers, Jails, Prisons, Law Enforcement
         Private corporations, worksite wellness, churches
         Retail pharmacies, mass vaccinators, non-practice locations offering vaccines to general public
         OB/GYN, pregnant women
         Local health departments, district depots
22 . If other Practice Specialty, please specify: