Resource Order Form

Immunization Resources

Use this form to order free immunization-related material from the Immunization Branch. Indicate the quantity of each item requested in the boxes below. For items that are available in packaged quantities, please indicate the number of packages you would like. If not marked, the materials are available on an individual basis.

DO NOT PUT ZERO - skip if you do not need item.

Please bookmark this link for future materials order requests.

Please allow 3-4 weeks for delivery. Thank you!

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* 1. Contact Information for Shipping

Contact Name *

Facility Name *

Provider ID Number (skip if unknown)

Street Address - NO PO BOXES *

City/Town *

ZIP/Postal Code *

Email Address *

Phone Number

Clinical Resources

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* 2. Lifetime Immunization Cards DHHS 1065
Available in packs of 100

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* 3. Adult Vaccine Administration Record (DHHS 4057)
Available in packs of 100

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* 4. NCIR Chart Stickers (Only for NCIR Providers)

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* 5. Vaccine Administration Log (VAL 122)
Available in packs of 100

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* 6. Invincible - English Shot Dodger #17

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* 7. Invincible - Spanish Invincible Shot Dodger #17

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* 8. Multitasker - English Shot Dodger #54

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* 9. Multitasker - Spanish Multitasker Shot Dodger #54

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* 10. Skeptic - English Shot Dodger #22

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* 11. Skeptic - Spanish Shot Dodger #22

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* 12. Worrywart - English - Shot Dodger #36

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* 13. Worrywart - Spanish Shot Dodger #36

Vaccine Ordering, Storage and Handling

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* 14. Refrigerator Warning Sticker (Do Not Unplug)

Information for Parents

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* 15. Reminder Postcards for Infants
Available in packs of 100

English

Spanish

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* 16. HALLMARK GREETING CARDS ENGLISH ONLY (Birthing Hospitals and Local Health Departments only!)

All Resources for Schools are OUT OF STOCK

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* 1. Contact Information for Shipping

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* 2. Lifetime Immunization Cards DHHS 1065 Available in packs of 100

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* 3. Adult Vaccine Administration Record (DHHS 4057) Available in packs of 100

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* 4. NCIR Chart Stickers (Only for NCIR Providers)

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* 5. Vaccine Administration Log (VAL 122) Available in packs of 100

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* 6. Invincible - English Shot Dodger #17

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* 7. Invincible - Spanish Invincible Shot Dodger #17

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* 8. Multitasker - English Shot Dodger #54

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* 9. Multitasker - Spanish Multitasker Shot Dodger #54

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* 10. Skeptic - English Shot Dodger #22

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* 11. Skeptic - Spanish Shot Dodger #22

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* 12. Worrywart - English - Shot Dodger #36

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* 13. Worrywart - Spanish Shot Dodger #36

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* 14. Refrigerator Warning Sticker (Do Not Unplug)

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* 15. Reminder Postcards for InfantsAvailable in packs of 100

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* 16. HALLMARK GREETING CARDS ENGLISH ONLY (Birthing Hospitals and Local Health Departments only!)

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* 17. OUT OF STOCK Kindergarten Postcard - English-front Spanish-Back

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* 18. OUT OF STOCK Kindergarten FAQ Flyer English 100 per pack

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* 19. OUT OF STOCK 7th Grade Postcard - English-front Spanish-back

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* 20. OUT OF STOCK 12th Grade Postcard (Front - English / Back - Spanish)

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* 21. Measles Poster

* 2. Lifetime Immunization Cards DHHS 1065
Available in packs of 100

* 3. Adult Vaccine Administration Record (DHHS 4057)
Available in packs of 100

* 5. Vaccine Administration Log (VAL 122)
Available in packs of 100

* 15. Reminder Postcards for Infants
Available in packs of 100