PROVIDER REQUEST FOR CHILDHOOD VACCINE
Fax Completed Request To:
Provider PIN#
Thurston County Public Health and Social Services
412 Lilly Rd NE
Olympia, WA, 98506
Telephone (360) 867-2548 Fax (360) 867-2608
1 9 3
SHIP TO:
DATE ORDERED:
SHIPPING ADDRESS:
Check If Any
Shipping Changes
CONTACT:
TELEPHONE: (
)
FAX: (
Monday
DELIVERY TIMES: Please specify all days
and hours your clinic is available to receive
vaccine. (e.g., 9AM-3PM)
AM
PM
___ to
___ .
Tuesday
AM
PM
___ to
___ .
)
Wednesday
AM
PM
___ to
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Thursday
AM
PM
___ to
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Friday
AM
PM
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Special Shipping Instructions:
MUST COMPLETE ALL FIELDS BELOW***
Vaccine
DT
(Pediatric)
DTaP
DTaP –
Hep B –
IPV**
DTaP –
IPV –
Hib**
Hep A
Description
Doses Used Doses On Vial Size
Minimum
Number of
Last Month Hand
(Doses) Order (Doses) Doses Ordered*
Diphtheria & Tetanus - 10x1 dose vial
DAPTACEL®
- 10x1 dose vial
Diphtheria & tetanus toxoids & acellular pertussis vaccine
PEDIARIX® - 10x1 dose vial
Diphtheria & tetanus toxoids and acellular pertussis, Hepatitis B, and
IPV combination vaccine
1
10
1
10
1
10
PENTACEL® - 5x1 dose vial
Diphtheria & tetanus toxoids and acellular pertussis, IPV, and
1
5
Haemophilus influenzae type b Conjugate combination vaccine
HAVRIX® - 10x1 dose vial
1
10
Hepatitis A Pediatric/Adolescent
(Pediatric)
®
ENGERIX-B - 10x1 dose vial
Hep B
1
10
Hepatitis B Pediatric/Adolescent
®
ActHIB - 5x1 dose vial
Hib
1
5
Haemophilus influenzae type b Conjugate
®
Hiberix - 10x1 dose vial
Hib
1
10
Haemophilus influenzae type b Conjugate (Booster Dose Only)
®
GARDASIL - 10x1 dose vial
Human Papillomavirus Quadravalent (Types 6, 11, 16,18) vaccine
HPV
1
10
(Only for adolescents eligible for state supplied vaccine)
IPOL® - 10 dose vial
IPV
10
10
Inactivated Poliovirus vaccine
®
Menactra - 5x1 dose vial
MCV4
1
5
Meningococcal (Groups A, C, Y & W-135) Conjugate vaccine
®
M-M-R II - 10x1 dose vial
MMR
1
10
Measles, Mumps, and Rubella combination vaccine
®
Prevnar - 10x1 dose syringe
PCV7
1
10
Pneumococcal Conjugate 7-valent
Pneumo
PNEUMOVAX 23® - 5 dose vial (Special Circumstances Only)
5
5
Pneumococcal vaccine polyvalent
23
RotaTeq® - 10x1 dose tube
Rota
1
10
Rotavirus (Pentavalent)
®
DECAVAC - 10x1 dose syringe
Td
1
10
Tetanus & diphtheria toxoids adsorbed
®
BOOSTRIX - 10x1 dose vial
Tdap
1
10
Tetanus & diphtheria toxoids and acellular pertussis vaccine
®
VARIVAX - 10x1 dose vial (Freezer Storage Only)
Varicella
1
10
Varicella vaccine
*See Back Page for ordering guidelines.
**Supplies of combination vaccines are limited; order only enough combination vaccine for children in the indicated age range
***Doses used last month and doses on hand for each vaccine, including vaccines not ordered, are required with every order
Order
Number:______________
LHJ Use Only
Order Entered / Approved
By:_____________________
DOH 348-015 10/2009 - Official Vaccine Order Form
DOH Use Only
Order Entry
Date:_________________
Washington State - Department of Health, Immunization Program CHILD Profile
Page 1 of 2
PROVIDER REQUEST FOR CHILDHOOD VACCINE
Vaccine
General Guidelines for Use*
Description
DT
 6 weeks of age up to the 7th birthday with pertussis contraindication
Diphtheria & Tetanus (sanofi pasteur)
(Pediatric)
DAPTACEL® Diphtheria & Tetanus toxoids  6 weeks of age up to the 7th birthday
DTaP
and acellular Pertussis vaccine (sanofi pasteur)
 2, 4 and 6 months of age needing all antigens
PEDIARIX® Diphtheria & Tetanus toxoids
 May be used for catch-up vaccination of children up to 7 years of age
DTaP –
and acellular Pertussis adsorbed, Hepatitis B,
who have not completed the primary series
Hep B –
and IPV combination vaccine
 Does not use to replace the birth dose of Hepatitis B
IPV
(GlaxoSmithKline)
 Individual antigen orders should be decreased to offset combination
vaccines ordered

Indicated for the primary doses of DTaP, IPV, and Hib series at 2, 4 and
PENTACEL® Diphtheria & Tetanus toxoids
6 months of age
DTaP –
and acellular Pertussis adsorbed, IPV, and
IPV –
 May be used for any dose of the primary Hib series for children 6 weeks
Haemophilus influenzae type b conjugate
Hib
of age up to the 5th birthday
combination vaccine (sanofi pasteur)
 See complete guidelines for considerations
HAVRIX® Hepatitis A vaccine,
Hep A
 1 year of age up to the 19th birthday
(Pediatric) Pediatric/Adolescent (GlaxoSmithKline)
ENGERIX-B® Hepatitis B vaccine,
 At birth up to the 19th birthday or who meet high risk criteria
Hep B
Pediatric/Adolescent (GlaxoSmithKline)
 DTaP/HepB/IPV does not replace the birth dose of Hepatitis B
ActHIB® Haemophilus influenzae type b
 6 weeks of age up to the 5th birthday
Hib
conjugate vaccine (sanofi pasteur)
Hiberix® Haemophilus influenzae type b
 12 months of age up to the 5th birthday (per ACIP recommendations)
Hib
conjugate vaccine (GlaxoSmithKline)
 Booster dose only
GARDASIL® Human Papillomavirus
 Females 9 years of age up to 19th birthday who are eligible for state
Quadrivalent (Types 6, 11, 16,18) vaccine
HPV
supplied vaccine (see the Guidelines for the Use of State Supplied
(Merck)
Vaccine for full details)
IPOL® Inactivated Poliovirus vaccine (sanofi  6 weeks of age up to the 19th birthday
IPV
pasteur)
Menactra® Meningococcal (Groups A, C, Y  11 years of age up to the 19th birthday
& W-135) Polysaccharide Diphtheria Toxoid  2 years of age up to the 19th birthday who meet high risk criteria
MCV4
Conjugate vaccine (sanofi pasteur)
M-M-R®II Measles, Mumps, and Rubella
 12 months of age up to the 19th birthday
MMR
combination vaccine (Merck)
Prevnar® Pneumococcal Conjugate 7-valent  2 months of age up to the 5th birthday
PCV7
vaccine (Wyeth)
Pneumo PNEUMOVAX 23® Pneumococcal
 Special Circumstances Only: high risk children only, 2 years of age up
Polyvalent vaccine (Merck)
23
to the 19th birthday.
RotaTeq® Rotavirus (Pentavalent) vaccine
 6 weeks of age through 32 weeks
Rota
(Merck)
DECAVAC® Tetanus & Diphtheria toxoids  7 years of age up to the 19th birthday for whom Tdap is contraindicated
Td
adsorbed (sanofi pasteur)
or unavailable
BOOSTRIX® Tetanus & Diphtheria toxoids  11 years of age up to the 19th birthday
and acellular Pertussis vaccine
Tdap
(GlaxoSmithKline)
 12 months of age up to the 19th birthday
Varicella VARIVAX® Varicella vaccine (Merck)
 Providers must be certified to order varicella vaccine
*For complete list of guidelines, see Immunization Guidelines for the Use of State-Supplied Vaccines located at:
http://www.doh.wa.gov/cfh/Immunize/documents/vacusage.pdf
Manufacturer Quality Control Office Telephone Numbers:
 GlaxoSmithKline, 866-475-8222 or 888-825-5249, www.gsk.com
 Merck, 800-609-4618 or 800-672-6372, www.merckvaccines.com
 sanofi pasteur, 800-822-2463, www.sanofipasteur.us
 Wyeth, 800-999-9384, www.wyeth.com
If you have a disability and need this document in another format, please call 1-800-322-2588 (711—TTY relay).
DOH 348-015 10/2009 - Official Vaccine Order Form
Washington State - Department of Health, Immunization Program CHILD Profile
Page 2 of 2