Vax.phila.gov
Community Flu Campaign 2020-2021 Registration FormThe Philadelphia Department of Public Health’s Community-based Flu Campaign (CFC) provides flu vaccine for health care providers to hold special clinic events offering flu vaccines to uninsured and insured people age 19 to 64+ in their communities. You may schedule this clinic with a community site, or PDPH can schedule you to work with a community site. To apply, please fill out this form by September 23, 2020. If your planned clinic is eligible, PDPH will contact you to participate as a clinical partner for the 2020-2021 flu season. Only clinics that have been pre-approved and confirmed will be authorized by the CFC program.Agreement To participate in the 2020-2021 Community-based Flu Campaign, please agree to the guidelines and requirements below, sign, and date this form. Flu vaccine provided by the Community-based Flu Campaign program is for all patients. Anybody who presents at a clinic is eligible to receive Community-based Flu Campaign flu vaccine. The Community-based Flu Campaign program provides vaccine and related supplies, including digital data loggers to monitor vaccine storage temperature. Providers may not charge or bill for Community-based Flu Campaign program vaccine or services to vaccinate participants.Your clinic will screen each patient for their age and document this screening on the Vaccine Administration Record (VAR form). You will vaccinate insured patients. Your clinic will supply a licensed and qualified clinician to administer vaccine. PDPH does not have nurses or staff available to staff your clinics.Your clinic is responsible for proper storage and handling of this federally-procured vaccine, including:Identifying digital data logger alarms (failure to respond to an alarm is a violation of CDC storage and handling regulations)Being responsible for vaccine lost if you fail to identify an alarmYour clinic will not use Community-based Flu Campaign vaccine on anybody under age 19.You must complete the online in-service and score at least 80% on the test. If you do not follow these requirements, this agreement will be terminated by PDPH. 621284058791CFC Coordinator (Person who has medical oversight for the clinic) New CFC provider for 2020-2021?Your name: __________________________________________________________________________________Work phone: ______________________________ Work fax: _________________________________________Cell phone: _______________________________ Email: _____________________________________________License number_________________ Signature___________________________________ Date ______________Clinic SiteFill out this form for your clinic. If you are applying to hold more than one clinic, please fill out a copy of this page for each clinic.Facility name: ________________________________________________ Facility type: _____________________Address: ________________________________________________________ ZIP: ________________________ Phone: _______________________________ Facility contact person ___________________________________Clinic Date: ____________________________________Clinic Time: ___________________________________-5588049530Drop-off site for supplies and vaccinesAddress: __________________________________________ ZIP: __________ Phone: _____________________-44005476250Primary site contact person (The person that’s going to be at the clinic)Name: ______________________________________________________________________________________Email: __________________________________________________________ Phone: _____________________-38100749300Secondary site contact person (The person who coordinates the clinic)Name: ______________________________________________________________________________________Email: __________________________________________________________ Phone: _____________________-38100577850Vaccine requestNumber of doses requested: ________________ (quantities of 10 only)Do you need nursing students to help at your clinic? Yes_________No__________List all individuals who will administer CDC vaccine. If you need room for more providers, just photocopy this page of the form. First nameLast namePhoneLicense number ................
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