2019 NYS Vaccines for Children Educational Attestation (Optional)

Dear Provider:
Completion of this survey is optional (no longer mandatory).
By signing your 2019 PPU, you attest completion of the required trainings.

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* 1. Please list the name and address of your provider office.

Provider Name

Address

Address 2

City/Town

County

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* 2. List your provider office's zip code.

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* 3. What is your provider office's VFC pin number?

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* 4. Enter your practice's email address, if applicable.

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NYS VFC Training Requirements

NYS VFC Training Requirements

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* 5. Please indicate why you are taking the trainings (select all that apply).

Our practice is enrolling in the VFC program for the first time

We are current VFC providers completing our annual renewal

There has been a change in our VFC program staffing

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* 6. Do you attest that you and the other VFC staff at your practice have taken the trainings required in the previous table?

Yes

No