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	317 Program

PATIENT ELIGIBILITY

SCREENING RECORD
A record of all patients 19 years of age or older 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 patient, guardian/individual of record, or by the health care provider. 317 Program eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure the adult’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 adult receiving vaccine. Providers using a similar form (paper-based or electronic) must capture all reporting elements included in this form.
1.	Patient Name:
(Last Name)	(First Name)	(MI)
2.	Date of Birth:	___ ___ / ___ ___ / ___ ___ ___ ___
3.	Guardian/Individual of Record:
(Last Name)	(First Name)	(MI)
4.	Primary Provider’s Name:
(Last Name)	(First Name)	(MI)
5.	To determine if an adult (19 years of age or older) is eligible to receive federal vaccine through the 317 program, at each immunization encounter/visit, enter the date and mark the appropriate eligibility category. If Column A or B is marked, the adult is eligible for the 317program. If Column C or D is marked, the adult is not eligible for federal 317 vaccines.

Date	ELIGIBLE for 317 Vaccine	NOT ELIGIBLE for 317 Vaccine
A	B	C	D
Has No Health

Insurance	Health insurance

covers no part of

vaccine cost	*Has health insurance

that covers vaccines	Health insurance deductible or co-pay

not met

*	Adult Medicaid covers most vaccines. Check if Medicare covers the cost of vaccine. If Medicare pays no portion of the vaccine, the patient is eligible for 317-funded vaccine; check Box B.

IMM-28A

JUL 16

IMM-28a, Patient Eligibility and Vaccination Record, Adult

ewhite

2016-06-29

NJDOH