Form IMM-50 "Yellow Fever Vaccine Program Acknowledgement of Program Requirements" - New Jersey

What Is Form IMM-50?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IMM-50 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form IMM-50 "Yellow Fever Vaccine Program Acknowledgement of Program Requirements" - New Jersey

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New Jersey Department of Health
VACCINE PREVENTABLE DISEASE PROGRAM
P.O. Box 369
Trenton, NJ 08625-0369
YELLOW FEVER VACCINE PROGRAM
ACKNOWLEDGEMENT OF PROGRAM REQUIREMENTS
This form is used by a NEW Uniform Stamp Holder applicant to acknowledge an understanding of program requirements.
Full Name of Responsible Physician (Stamp Holder)
Mailing Address
Medical License Number
City
State
Zip Code
Phone
The responsible physician should review and initial each of the following items:
Initials
Advisory Committee of Immunization Practices (ACIP) Statement
I acknowledge that I have read and understand the recommendations outlined by the
ACIP regarding the administration of yellow fever vaccine. ............................................................... ______________
Centers for Disease Control and Prevention Training Statement
I acknowledge that I and the Yellow Fever Vaccine Coordinators have viewed the
two-part CDC yellow fever webinar available through the CDC website at
http://www.cdc.gov/travel-training/?s_cid=yellowfever_005. All other pertinent personnel
have also taken the training. (Attach all transcripts with scores.) ..................................................... ______________
Yellow Fever Vaccine Storage Statement
I acknowledge that I have read and understand the requirements outlined by the
manufacturer, ACIP, and New Jersey Department of Health, Vaccine Preventable
Disease Program regarding proper storage of yellow fever vaccine and will be compliant
with the recommendations................................................................................................................. ______________
Vaccine Information Sheet (VIS) Statement
I acknowledge that I understand that the most recent version of the VIS on yellow fever
vaccine must be provided to a person prior to the administration of the yellow fever
vaccine. ............................................................................................................................................. ______________
New Jersey Immunization Information System (NJIIS)
I acknowledge that I understand that I am required to enter all yellow fever vaccines
administered into NJIIS and follow all NJIIS requirements. ............................................................... ______________
Protocol Development Statement
I acknowledge that I understand that I am required to create Standing Orders for Yellow
Fever Vaccine and Vaccine Management Plan to be shared with Yellow Fever Vaccine
Coordinators and all other pertinent personnel. Both documents will be available at all
approved Vaccination Centers........................................................................................................... ______________
Audit Statement
I acknowledge that I understand that the New Jersey Department of Health, Vaccine
Preventable Disease Program may conduct an audit, announced or unannounced, of
records, documents, protocols, and any other aspect of the Yellow Fever Vaccine
Program at any approved Vaccination Center. .................................................................................. ______________
SIGNATURE OF RESPONSIBLE PHYSICIAN
Signature of Responsible Physician
Date
New applicants should reference the Yellow Fever Program Manual to ensure all required forms are submitted. Forms must
be mailed to the New Jersey Department of Health, Vaccine Preventable Disease Program at the address above, faxed to the
Vaccine Preventable Disease Program, Attention: Yellow Fever Vaccine Program at 609-826-4866, or emailed to
yf.vaccine@doh.nj.
gov.
IMM-50
FEB 16
New Jersey Department of Health
VACCINE PREVENTABLE DISEASE PROGRAM
P.O. Box 369
Trenton, NJ 08625-0369
YELLOW FEVER VACCINE PROGRAM
ACKNOWLEDGEMENT OF PROGRAM REQUIREMENTS
This form is used by a NEW Uniform Stamp Holder applicant to acknowledge an understanding of program requirements.
Full Name of Responsible Physician (Stamp Holder)
Mailing Address
Medical License Number
City
State
Zip Code
Phone
The responsible physician should review and initial each of the following items:
Initials
Advisory Committee of Immunization Practices (ACIP) Statement
I acknowledge that I have read and understand the recommendations outlined by the
ACIP regarding the administration of yellow fever vaccine. ............................................................... ______________
Centers for Disease Control and Prevention Training Statement
I acknowledge that I and the Yellow Fever Vaccine Coordinators have viewed the
two-part CDC yellow fever webinar available through the CDC website at
http://www.cdc.gov/travel-training/?s_cid=yellowfever_005. All other pertinent personnel
have also taken the training. (Attach all transcripts with scores.) ..................................................... ______________
Yellow Fever Vaccine Storage Statement
I acknowledge that I have read and understand the requirements outlined by the
manufacturer, ACIP, and New Jersey Department of Health, Vaccine Preventable
Disease Program regarding proper storage of yellow fever vaccine and will be compliant
with the recommendations................................................................................................................. ______________
Vaccine Information Sheet (VIS) Statement
I acknowledge that I understand that the most recent version of the VIS on yellow fever
vaccine must be provided to a person prior to the administration of the yellow fever
vaccine. ............................................................................................................................................. ______________
New Jersey Immunization Information System (NJIIS)
I acknowledge that I understand that I am required to enter all yellow fever vaccines
administered into NJIIS and follow all NJIIS requirements. ............................................................... ______________
Protocol Development Statement
I acknowledge that I understand that I am required to create Standing Orders for Yellow
Fever Vaccine and Vaccine Management Plan to be shared with Yellow Fever Vaccine
Coordinators and all other pertinent personnel. Both documents will be available at all
approved Vaccination Centers........................................................................................................... ______________
Audit Statement
I acknowledge that I understand that the New Jersey Department of Health, Vaccine
Preventable Disease Program may conduct an audit, announced or unannounced, of
records, documents, protocols, and any other aspect of the Yellow Fever Vaccine
Program at any approved Vaccination Center. .................................................................................. ______________
SIGNATURE OF RESPONSIBLE PHYSICIAN
Signature of Responsible Physician
Date
New applicants should reference the Yellow Fever Program Manual to ensure all required forms are submitted. Forms must
be mailed to the New Jersey Department of Health, Vaccine Preventable Disease Program at the address above, faxed to the
Vaccine Preventable Disease Program, Attention: Yellow Fever Vaccine Program at 609-826-4866, or emailed to
yf.vaccine@doh.nj.
gov.
IMM-50
FEB 16