New Jersey Department of Health

Vaccine Preventable Disease Program

P.O. Box 369

Trenton, NJ 08625-0369

YELLOW FEVER VACCINE PROGRAM

ACKNOWLEDGEMENT OF PROGRAM REQUIREMENTS

This form is used by a NEW Uniform Stamp Holder applicant to acknowledge an understanding of program requirements.

Full Name of Responsible Physician (Stamp Holder)

Mailing Address

Medical License Number

City

State

Zip Code

Phone

The responsible physician should review and initial each of the following items:

Initials

Advisory Committee of Immunization Practices (ACIP) Statement

I acknowledge that I have read and understand the recommendations outlined by the ACIP regarding the administration of yellow fever vaccine.	______________

Centers for Disease Control and Prevention Training Statement

I acknowledge that I and the Yellow Fever Vaccine Coordinators have viewed the two‑part CDC yellow fever webinar available through the CDC website at http://www.cdc.gov/travel-training/?s_cid=yellowfever_005. All other pertinent personnel have also taken the training. (Attach all transcripts with scores.)	______________

Yellow Fever Vaccine Storage Statement

I acknowledge that I have read and understand the requirements outlined by the manufacturer, ACIP, and New Jersey Department of Health, Vaccine Preventable Disease Program regarding proper storage of yellow fever vaccine and will be compliant with the recommendations.	______________

Vaccine Information Sheet (VIS) Statement

I acknowledge that I understand that the most recent version of the VIS on yellow fever vaccine must be provided to a person prior to the administration of the yellow fever vaccine.	______________

New Jersey Immunization Information System (NJIIS)

I acknowledge that I understand that I am required to enter all yellow fever vaccines administered into NJIIS and follow all NJIIS requirements.	______________

Protocol Development Statement

I acknowledge that I understand that I am required to create Standing Orders for Yellow Fever Vaccine and Vaccine Management Plan to be shared with Yellow Fever Vaccine Coordinators and all other pertinent personnel. Both documents will be available at all approved Vaccination Centers.	______________

Audit Statement

I acknowledge that I understand that the New Jersey Department of Health, Vaccine Preventable Disease Program may conduct an audit, announced or unannounced, of records, documents, protocols, and any other aspect of the Yellow Fever Vaccine Program at any approved Vaccination Center.	______________

Signature of Responsible Physician
Signature of Responsible Physician	Date
New applicants should reference the Yellow Fever Program Manual to ensure all required forms are submitted. Forms must be mailed to the New Jersey Department of Health, Vaccine Preventable Disease Program at the address above, faxed to the Vaccine Preventable Disease Program, Attention: Yellow Fever Vaccine Program at 609-826-4866, or emailed to yf.vaccine@doh.nj.gov.

IMM-50

FEB 16

IMM-

SEP 15

ewhite

2015-09-22

NJDOH