The H1N1 Provider Enrollment Agreement specifies the conditions of participation in the 2009 Influenza A (H1N1) vaccination effort. The enrollment form must be completed and signed and submitted to the State Immunization Program prior to requesting the vaccine. Enrollment will not automatically qualify a provider to receive vaccine. Allocations will be determined by vaccine availability, quantity, presentation, shipment dates and provider profiles. Please take time to complete your provider profile as it will be an integral part of the distribution process.

PDF Documents to download:

H1N1 Vaccine Administration (pdf)

H1N1 ENROLLMENT MEMO and Instructions (pdf)

H1N1 Enrollment Forms (pdf)

Handling Instructions for H1N1 and Is your unit reliable (pdf)