MAINE IMMUNIZATION PROGRAM
MAINE IMMUNIZATION PROGRAM
PENTACEL MONTHLY USAGE REPORT
USE THIS FORM ONLY UNTIL JANUARY 1ST, 2009
Please fax back to 207-287-3347
|Pin # ________________ Person Completing Form _____________________________________________________________________________________ |
|Facility Name ____________________________________________________________ Phone ____________________________________ | | |
|Address __________ |__________________________________________________________ |Month-Year Reporting ______________________________ |
|_________________________________________________________________ State __________________________Zip __________________ | | |
|City ______________________________________________________________Date Report Completed _________________________________________ |
| | | | | | | | | | | | | | | | | | | |Number of Doses Administered within Age Groups | | |Subtract |Subtract |Subtract |Add |Add |Equals | | | | | | | | | | | | |Total | |Total | | | | | | | | | | | | | | | | | |Doses | |Given |Total |Total |Total | |Balance | |Vaccine |NDC # |Dose # | | | | | | | | |Given |Previous |(Per |Doses |Doses |Doses |Amount |In | | | | | ................
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