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NC Department of Health and Human Services
Women's and Children's Health Home
N.C. Public Health Home
North Carolina Immunization Branch

Health Care Providers

Free Immunization Resources for Clinicians

Click on each item to view a PDF version and print a copy.  If you’d like to order free copies use this order form

(*- Denotes that copies cannot be ordered from NCIP. )


Lifetime Immunization Card (DHHS 1065) (PDF, 230 KB)

Vaccine Administration Record (DHHS 4041) (PDF, 656 KB)

Adult Vaccine Administration Record (DHHS 4057) (PDF, 1016 KB)

Adult Vaccination Record (wallet size) (DHHS 4040) (PDF, 81 KB)

Vaccine Administered Log (VAL 121) (PDF, 710 KB)

NCIR Chart stickers (PDF, 783 KB)

Zoster Pocket Guide external link (PDF)

School Entry Requirements (Pocket Guide) (PDF, 651 KB)

Vaccine Adverse Event Reporting System form (PDF, 70 KB)

Vaccine Administration Error Reporting

Vaccine Ordering, Storage and Handling

Vaccine Storage and Handling Kit*

Vaccine Requisition Form (PDF, 249 KB)

Refrigerator Temperature Storage Log (PDF, 160 KB)

Freezer Temperature Storage Log (PDF, 160 KB)

Refrigerator Warning Sticker (Do Not Unplug) (PDF, 554 KB)

Quilt Checklist for Vaccine Deliverers (PDF, 320 KB)

Vaccine Transfer Form (DHHS 4058) (PDF, 43 KB)

Borrowing Policy Memo* (PDF, 127 KB) and Borrowing Policy Form* (PDF 61, KB)

State and Federal Rules and Laws

Vaccine Injury Compensation external link

NC Immunization Laws

Medical Exemption Statement and Physician's Request for Medical Exemption Forms

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