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 Ped) 10
 Tdap 10
 DTaP 10
 DTaP/Hib (4th dose only) 5
 EIPV (Enhanced Inactivated Poliovirus) 10 dose vial
 Flu (>= 4 years of age) 10 dose vial
 Flu-PF (6-23 months) 10 single dose syringes
 Flu (>=6 months of age) 10 dose vial
 Hepatitis A Pediatric (Hep A) 10
 Hepatitis B (pediatric & adolescent) 10
 Hib 5
 Measles-Mumps-Rubella (MMR) 10
 Meningococcal (MCV4) 5
 Pediarix (5-in-1 vaccine) 10
 Pneumococcal Conjugate 5
 PPD (Tuberculin Skin - Testing) - 10 dose vial For Public Health Offices Only 10
 PPD (Tuberculin Skin - Testing) - 50 dose vial For Public Health Offices Only 50
 Tetanus-Diphtheria (Td Adult) 10
 Rotavirus 10
 HPV vaccine 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
 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
 Tdap VIS (50/pad)  Rotavirus VIS (50/pad)
     HPV VIS (50/pad)
 DTaP VIS (50/pad)  Certificate of Immunization
 POLIO VIS (50/pad)  Vaccine Administration Record
 MMR VIS (50/pad)  Vaccine Order Forms
 HIB VIS (50/pad)  Monthly Doses Admin. Report
 TD VIS (50/pad)  Ring Bound Charts
 Hep B VIS (50/pad)  Temperature Charts
 Hep A VIS (50/pad)  Transfer Vaccine Form
 Varicella VIS (50/pad)  Wastage Report Form
 Influenza VIS (50/pad)  Immunization Cards
 Meningococcal VIS (50/pad)  Red pens for Dickson Therm
 Pneumococcal (50/pad)  White Follow-up Cards
 Pediarix - use an individual VIS for each vaccine in the combination  4 in Disks for Dickson Therm.
*Questions regarding vaccine orders, please contact the Immunization Program - Phone 605-773-4963, Fax 605-773-4113 (Rev. 09/07)

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Updated 10/03/2007