Get the free Vaccine Report Form 09-1113 - Florida Department of Health

Florida Vaccines for Children Program Additional Information Form Provider's Name: AFC PIN: Delivery Address: Telephone Number: Fax Number: Contact Person: Today's Date: NOTES: (use this section to

How to fill out vaccine report form 09-1113

How to fill out vaccine report form 09-1113:

1. Start by entering the date at the top of the form in the designated space. Make sure to write the correct date in the format specified (e.g., MM/DD/YYYY).
2. Next, provide your personal information such as your full name, date of birth, and contact details. Fill in these details accurately and legibly so that there are no errors.
3. In the section labeled "Vaccine Information," you will need to provide details about the vaccine you received. This includes the vaccine name, manufacturer, lot number, and expiration date. Refer to the vaccine vial or packaging for this information.
4. Indicate the date of your vaccination in the "Date of Vaccination" field. Make sure to enter the correct date on which you received the vaccine.
5. If applicable, fill in any additional information required, such as the administering facility or healthcare provider's name and contact information.
6. Review the completed form to ensure all the information provided is accurate and complete. Double-check the spelling and accuracy of the details entered.

Who needs vaccine report form 09-1113:

The vaccine report form 09-1113 may be required by healthcare facilities, clinics, or vaccination centers to track and document individuals who have received vaccinations. This form serves as a record of the vaccine received, including important details such as the vaccine name, lot number, and expiration date. It helps maintain accurate records and facilitates tracking and monitoring of vaccine administration. The exact requirements for using this form may vary depending on local regulations and guidelines.

For pdfFiller’s FAQs

What is vaccine report form 09-1113?

Vaccine report form 09-1113 is a form used to report information about vaccines administered.

Who is required to file vaccine report form 09-1113?

Healthcare providers and facilities that administer vaccines are required to file vaccine report form 09-1113.

How to fill out vaccine report form 09-1113?

To fill out vaccine report form 09-1113, you need to provide details about the vaccines administered, including the type of vaccine, dosage, date of administration, and patient information.

What is the purpose of vaccine report form 09-1113?

The purpose of vaccine report form 09-1113 is to track and monitor the administration of vaccines to ensure public health and safety.

What information must be reported on vaccine report form 09-1113?

Information such as the type of vaccine, dosage, date of administration, patient details, and healthcare provider information must be reported on vaccine report form 09-1113.

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