Provider Information: How to Request 2009 H1N1 Influenza Vaccine

Vaccine Safety

Vaccine Safety Links

Step 1: Pre-register

PRE-REGISTRATION FOR 2009 H1N1 INFLUENZA VACCINE IS TEMPORARILY CLOSED, AS WE ARE NEARING THE TOTAL ALLOWED VACCINE RECEIVING SITES STATEWIDE. PLEASE CHECK BACK TO SEE IF WE MAY ACCEPT ADDITIONAL PRE-REGISTRATION APPLICATIONS IN THE NEAR FUTURE

For new providers whose facility or practice has not already pre-registered for H1N1 vaccine, please complete your pre-registration form here.

H1N1 Vaccination Pre-registration Form for Clinicians (Note: This link is temporarily closed)

Preregistration Resources:

Vaccine Distribution Background Document

Vaccine Distribution Pre-Registration Instructions

Step 2: Receive PIN and Ordering Packet from ADHS Immunization Program Office

Pre-registered providers will receive a unique PIN and packet containing the order form, provider agreement, and other important information. This PIN will be required for placing an order. Orders will not be accepted until a signed provider agreement has been filed with ADHS.

Sample H1N1 Ordering Packet

Step 3: Using PIN, complete ordering packet forms

COMPLETE ONLINE FORMS HERE: For providers who wish to submit required data and forms online. Other submission forms are available as outlined in the ordering packet.

Provider Agreement

Order/Reorder H1N1 Form

Step 4: Report on a Weekly Basis

For providers who wish to report doses administered online, please use the following reporting form - H1N1 Vaccine Doses Administered Aggregate Counts Form

Please visit http://www.cdc.gov/flu for national updates on flu information. Information on flu activity in Arizona can be found at http://www.azdhs.gov/phs/oids/epi/flu/index.htm

Note: A number of the links on this page are PDF files and require Acrobat Reader^™to view.