FamilyCare B, C and D vaccines are not VFC eligible On/After 07/01/2014, and reimbursed directly through Medicaid

Edit Immunization

Medical Facility: {{model.administeredFacilityName}}

Vaccine ID

Combo

Admin Route

Admin Route is required

Admin Site

Admin Site is required

Funding Source

Funding Source is required

Date Received

Please enter a valid date Date is required Immunization date must be later than Birth Date Date received cannot be later than today Date received cannot be later than ReVaccinate Date

Dose VFC Eligibility

VFC Eligibility is required

Lot Number

Lot Number is required

Expiration Date

Lot#

Lot Number is required Invalid Lot Number

Expiration Date

Please enter a valid date Expiration Date is required Expiration date must be later then the date received Immunization Date must be earlier than Expiration date

MFR

MFR is required

Reason for Visit

Reason is required

Date Added

Please enter a valid date

Dosage Amount

Invalid Dosage Amount

Dosage Unit

Invalid Dosage Unit

NJIIS Inventory Used

Request for ReVaccination

Partially Administered

Comments

Additional Comments

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