New Jersey Department of Health

Vaccine Preventable Disease Program

Vaccines for Children Program

PO Box 369

Trenton, NJ 08625-0369

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

REQUEST TO UPDATE PROVIDER INFORMATION

This form is to be used by participating Vaccines for Children (VFC) and 317 Program Providers to have your office information updated in the New Jersey Inventory Management, Order and Distribution System (NJIMODS).

Please email the form to vfc@doh.nj.gov.

CHANGE IN OFFICE INFORMATION
Provider PIN

Effective Date of Address Change

Office Name

Address

City

County

Zip Code

Phone Number

Fax Number

Office Email Address

Office

Delivery

Hours:	Tuesday:

Wednesday:

Thursday:

Friday:

CHANGE OF VACCINE COORDINATORS
PRIMARY VACCINE COORDINATOR

(Vaccine Coordinator must have taken NJIIS and IMODS training in the past two years.)
First Name

Last Name

Email Address

Phone Number

NJIIS Training Date

NJIMODS Training Date

BACKUP VACCINE COORDINATOR

(Vaccine Coordinator must have taken NJIIS and IMODS training in the past two years.)
First Name

Last Name

Email Address

Phone Number

NJIIS Training Date

NJIMODS Training Date

CHANGES REQUESTED BY
Requested by (Print or Type Name)

Signature	Date

IMM-48

APR 16

ewhite

2015-07-31

njdoh