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Influenza Immunization Declination PH BROOKVILLE PH CLEARFIELD PH CONNELLSVILLE PH CORPORATE PH DUBOIS PH ELK PH HUNTINGTON PH MON VALLEY PH TYRONE PH CNI HELPMATES PH PHYSICIAN NETWORK JEFFERSON

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What is this is your shot?

This is a form to report vaccine administration.

Who is required to file this is your shot?

Healthcare providers are required to file this form.

How to fill out this is your shot?

You can fill out this form online or submit a paper copy.

What is the purpose of this is your shot?

The purpose of this form is to track and report vaccine doses administered.

What information must be reported on this is your shot?

Information such as patient's name, date of birth, vaccine type, lot number, and administration site must be reported.

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