Monkeypox Pre-Registration Form


General
Organization Name: *
Organization Type: *
 
 
Other (specify): **
Do you attest to store, handle, administer, and report JYNNEOS or ACAM2000 vaccines in accordance with the CDC Monkeypox Vaccination Program Provider Agreement?: *
Note: Vaccine administration data elements required to be submitted to VIIS will be in accordance with VDH data exchange requirements and inventory and wastage reporting will be through VaxMaX.
Attested by?: *
Physical Address
Organization Phone #: *
-
Fax #:
Address Line 1: *
Zip Code: *
Address Line 2:
City: *
   
Are you currently using VIIS?: *
If Yes, What is your VIIS Org Code: **
How do you report immunizations to VIIS? *
What is the name of your EMR (Electronic Medical Record): **


  Zip  

  Success!  
  Warning!  
    If you are unable to attest to the CDC requirements, you will not be allowed to complete this pre-registration.
Primary Contact Info
Title
Legal First Name*
Last Name*
Middle Initial
Email*
Phone*
ex:(123) 456-7890 - 1234
-
Backup Contact Info
Title
Legal First Name**
Last Name**
Middle Initial
Email**
Phone**
ex:(123) 456-7890 - 1234
-







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