South Dakota Department of Health

SOUTH DAKOTA DEPARTMENT OF HEALTH
REQUISITION FOR SHIPMENT OF BIOLOGICALS

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Dear Provider:

Vaccine orders or form orders will no longer be accepted using this online form. Please fax your order in to the Vaccine Management Specialist at 605-773-4113. To download a paper form please follow this link: http://doh.sd.gov/PDF/vaccine.pdf You may also send it through the mail to:

Attn: Immunization Management Specialist

615 E Fourth St

Pierre, SD 57501

Thank you!

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Shipping Carton, Ice Packs MUST BE RETURNED within 48 Hours after Receipt of Shipment

Provider Name		Provider Number
Address		Contact Person
City		Phone
State	Zip	Shipping Instructions

DESCRIPTION OF ARTICLE	Minimum Quantity Available For Order	QUANTITIY in doses only
Diphtheria-Tetanus (DT) (Pediatric)	10
Tetanus-Diphtheria (Td) (Children 7 through 10 years of age only)	10
Tdap	10
DTaP	10
DTaP/Hib (4th dose only)	5
EIPV (Enhanced Inactivated Poliovirus)	10 dose vial
Hepatitis A (pediatric)	10
Hepatitis B (pediatric & adolescent)	10
Hib	5
HPV vaccine	10
Measles-Mumps-Rubella (MMR)	10
Meningococcal (MCV4)	5
Pediarix (DTaP-EIPV-Hepatitis B combination)	10
Pentacel (DTaP-Hib-EIPV combination)	5
Pneumococcal Conjugate	10
Rotavirus Vaccine (RotaTeq by Merck) (Three dose series)	10
Rotavirus Vaccine (Rotarix by GSK) (Two dose series)	10
Varicella (chickenpox vaccine) Please allow up to 20 working days for delivery. Varicella vaccine will be shipped to your facility directly from manufacturer.	10
PPD (Tuberculin Skin Test Antigen) - 10 dose vial For Public Health Offices Only	10
PPD (Tuberculin Skin Test Antigen) - 50 dose vial For Public Health Offices Only	50
WE CAN NO LONGER BREAK UP VACCINE ORDERS INTO SINGLE DOSES DUE TO FEDERAL GUIDELINES.

(Doses requested may be adjusted by DOH Immunization Program)
Signature of Receiving Agent:______________________________________ Date Received: ______________________

FORMS & VIS ORDER FORM

Provider Name

Provider Number

DESCRIPTION OF ARTICLE	QUANTITY	DESCRIPTION OF ARTICLE	QUANTITY
DTaP VIS (50/pad)		Vaccine Adverse Event Reporting form
Hepatitis A VIS (50/pad)		Certificate of Immunization
Hepatitis B VIS (50/pad)		Vaccine Administration Record
HIB VIS (50/pad)		Vaccine Order Forms
HPV VIS (50/pad)		Monthly Doses Admin. Report
Influenza VIS - Inactivated (50/pad)		Ring Bound Charts
Influenza VIS - Live/Intranasal (50/pad)		Temperature Logs
Meningococcal VIS (50/pad)		Transfer Vaccine Form
MMR VIS (50/pad)		Wastage Report Form
Pneumococcal (50/pad)		Immunization Cards
POLIO VIS (50/pad)		SDIIS Reminder/Recall postcards (50/pkg)
Rotavirus VIS (50/pad)		Gel Refrigerator Thermometer
Tdap/Td VIS (50/pad)		Gel Freezer Thermometer
Varicella VIS (50/pad)		Dickson Recorder
Your Baby's First Vaccines Multi VIS (50/pad)		Red pens for Dickson Recorder (6/pkg)
After the Shots... (50/pad)		4 inch Disks for Dickson Recorder(60/pkg)

*Questions regarding vaccine orders, please contact the Immunization Program - Phone 605-773-4963, Fax 605-773-4113 (Rev. 12/08)