SOUTH DAKOTA DEPARTMENT OF HEALTH
REQUISITION FOR SHIPMENT OF BIOLOGICALS
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)
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Updated 12/01/2008