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NC Department of Health and Human Services
Women's and Children's Health Home
N.C. Public Health Home
 
 
North Carolina Immunization Branch

Health Care Providers

Free Immunization Resources for Clinicians

Click on each item to view a PDF version and print a copy.  If you’d like to order free copies use this order form

Clinical

Lifetime Immunization Card (DHHS 1065) (PDF, 230 KB)

Vaccine Administration Record (DHHS 4041) (PDF, 656 KB)

Adult Vaccine Administration Record (DHHS 4057) (PDF, 1016 KB)

Adult Vaccination Record (wallet size) (DHHS 4040) (PDF, 81 KB)

Vaccine Administered Log (VAL 121) (PDF, 710 KB)

NCIR Chart stickers (PDF, 783 KB)

Rash Illnesses in Children poster (not available electronically)

Zoster Pocket Guide external link (PDF)

School Entry Requirements (Pocket Guide) (PDF, 715 KB)

Vaccine Adverse Event Reporting System form (PDF, 70 KB)

Vaccine Administration Error Reporting

Vaccine Ordering, Storage and Handling

Vaccine Storage and Handling Kit

Vaccine Requisition Form (PDF, 249 KB)

Refrigerator Temperature Storage Log (PDF, 160 KB)

Freezer Temperature Storage Log (PDF, 160 KB)

Refrigerator Warning Sticker (Do Not Unplug) (PDF, 554 KB)

Quilt Checklist for Vaccine Deliverers (PDF, 320 KB)

Vaccine Transfer Form (DHHS 4058) (PDF, 43 KB)

Borrowing Policy Memo (PDF, 127 KB) and Borrowing Policy Form (PDF 61, KB)

State and Federal Rules and Laws

Vaccine Injury Compensation (NC Immunization law) (PDF, 48 KB)

NC Immunization Rules/Laws Booklet (PDF, 94 KB)

Medical Exemption Statement Form (DHHS 3987) (PDF, 517 KB)

Physicians Request for Medical Exemption Form (DHHS 3995) (PDF, 41 KB)

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