New Jersey Department of Health

Vaccine Preventable Disease Program

Yellow Fever Vaccine Program

P.O. Box 369

Trenton, NJ 08625-0369	DESIGNATION OF ADDITIONAL

YELLOW FEVER VACCINATION CENTERS
This form is used to designate an additional facility under the jurisdiction of the Uniform Stamp Holder to administer Yellow Fever vaccine.

uniform stamp holder requesting additional vaccination center
Full Name of Responsible Physician (Stamp Holder)

Mailing Address

Medical License Number

City

State

Zip Code

Phone

Physical Address

Email Address

City

State

Zip Code

Uniform Stamp Number

Effective Date of Change

designated yellow fever vaccination center
Legal Name of Designated Facility

Mailing Address

City

State

Zip Code

Phone

Fax

Email Address

Shipping Address

City

State

Zip Code

Phone

Fax

Email Address

designated yellow fever coordinator
Name of Coordinator

Physician	Pharmacist

Nurse	Physician Assistant	New Jersey Professional Board License/Certificate

Position

Mailing Address

City

State

Zip Code

Phone

Fax

Email Address

* 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. Include a transcript with scores for the CDC Yellow Fever Vaccine Course for any new pertinent staff (including those not listed on this form).

Signature of Responsible Physician
Signature of Responsible Physician	Date

Stamps are issued to the Uniform Stamp Holder/prescribing physician and will remain under the jurisdiction of that person.

IMM-51

FEB 16

IMM-

SEP 15	Page 1 of 1 Pages.

ewhite

2015-09-22

NJDOH