New Jersey Department of Health

Vaccines for Children Program

PO Box 369

Trenton, NJ 08625-0369

Phone: 609-826-4862 Fax: 609-826-4868

Email: VFC@doh.nj.gov	Vaccines for Children (VFC) Program

PATIENT ELIGIBILITY

SCREENING RECORD
A record of all children 18 years of age or younger who receive immunizations must be kept in the health care provider’s office for 3 years or longer depending on state law. The record may be completed by the parent, guardian, individual of record, or by the health care provider. VFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine. Providers using a similar form (paper-based or electronic) must capture all reporting elements included in this form.
1.	Child’s Name:
(Last Name)	(First Name)	(MI)
2.	Child’s Date of Birth:	___ ___ / ___ ___ / ___ ___ ___ ___
3.	Parent/Guardian/Individual of Record:
(Last Name)	(First Name)	(MI)
4.	Primary Provider’s Name:
(Last Name)	(First Name)	(MI)
5.	To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the VFC program, at each immunization encounter/visit, enter the date and mark the appropriate eligibility category. If Column A-D is marked, the child is eligible for the VFC program. If Column E, F or G is marked, the child is not eligible for federal VFC vaccine.

Date	ELIGIBLE for VFC Vaccine	NOT ELIGIBLE for VFC Vaccine
A	B	C	D	E	F	G
Medicaid Enrolled	No Health

Insurance	American Indian or

Alaskan

Native	*Underinsured	Has health insurance

that covers vaccines	**Other Underinsured	***Enrolled in NJ FamilyCare Plan B, C or D (CHIP)

*	Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC).

**	Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the VFC program because the provider is not a Federally Qualified Health Center.

***	Children enrolled in NJ FamilyCare Plans B, C and D are in the Children’s Health Insurance Program (CHIP). These children are considered insured and are not eligible for vaccines through the VFC program.

IMM-28

JUL 16

imm-28, Patient Eligibility and Vaccination Record, Child

ewhite

2016-06-29

NJDOH