February 18, 2009 

Important Influenza Vaccine Advanced Ordering Instructions 

Dear Vaccines for Children (VFC) Program Participants: 

The DHSS Immunization Program has begun preparation for the 2009-2010 
influenza season. It is very important for the Immunization program to 
know how many doses of each influenza vaccine formulation our customers 
plan to order during the coming flu season. 

Below is a list of influenza vaccine formulations recommended for different 
age groups that will be available through the VFC Program during the 2009-
2010 influenza season. Please review these vaccine formulations carefully 
before completing the enclosed Influenza Vaccine Advanced Order Form. The 
VFC Program will make every effort to accommodate your request given the 
availability of the vaccine. 

  · Preservative-FREE (6-35 months)
  · Preservative-FREE (36 months-7 years of age)
  · Preservative-containing (8-18 years of age)
  · Live Intranasal Preservative-Free (2-18 years of age)


Influenza Advance Ordering and Form Instructions:

The Influenza Advanced Order Form is enclosed. Please complete this form to 
pre-book the influenza vaccine for the 2009-2010 influenza season and fax it 
to (800) 318-0810. Include the number of doses requested and your preferred 
formulation. Contact the Immunization Program at (800) 282-8672 or (302) 
744-1060 if you should require additional information regarding the VFC 
influenza vaccine supply or have questions regarding the advanced ordering 
process. 


MSL/ml 
Enclosure 
DHSS Immunization Program • Bureau of Communicable Disease 
Thomas Collins Building • Suite #4 
540 S. DuPont Highway • Dover, DE 19901 
(800) 282-8672 


VFC Influenza Vaccine 
Advanced Order Form 
2009-2010

  Contact: _____________________________   PIN: ______________________________

 Facility: _____________________________  Date: ______________________________

  Address: _____________________________ Phone: (_______) _______ -___________

    Email: _____________________________   Fax: (_______) _______ -___________

Deliveries Received
        MONDAY From: _____to_____      TUESDAY From: _____to_____ 

     WEDNESDAY From: _____to_____     THURSDAY From: _____to_____ 

        FRIDAY From: _____to_____ 

VFC must receive all orders for the 2009-10 Influenza Season by:
Tuesday, March 31, 2009 

Submit one form per facility/PIN for your entire 2009-2010 VFC influenza 
vaccine supply.

DIRECTIONS: Complete the boxes below with your requested number of doses 
for influenza vaccine. Base your request on current VFC eligibility criteria 
(see the box below), the influenza vaccine dosage schedule, and last season's 
demand. Orders will be limited based on vaccine availability and your 
facility's patient enrollment. Orders could also be affected by manufacturer/
CDC delay or supply. Please keep a copy of your order and your fax confirmation. 

VFC Eligibility determined by age <19 years, meeting one or more of the 
following:[Medicaid / Medicaid HMOs / No Health Insurance / American Indian or 
Alaskan Native / Underinsured at FQHCs/RHCs]

All children ages 6 months to 18 years old are recommended to receive flu 
vaccination. 

Vaccine for VFC Patients: Doses Requested 
  · 6 months -35 months (multiples of 10) - Injectable         Quantity:______

  · 36 months -7 years of age (multiples of 10) - Injectable   Quantity:______ 

  · 8 -18 years of age (multiples of 10) - Injectable          Quantity:______ 

  · 2 -18 years of age (multiples of 10) - Intranasal          Quantity:______ 

VIS RequestedVaccine Information Sheets (VIS) 
  · English Influenza Vaccine                                  Quantity:______

  · Spanish Influenza Vaccine                                  Quantity:______ 

  · English Live Intranasal Vaccine                            Quantity:______ 

  · Spanish Live Intranasal Vaccine                            Quantity:______

YOUR ADVANCED ORDER FOR VFC INFLUENZA VACCINE WILL BE CONFIRMED VIA MAIL OR 
FAX INDICATING THE TOTAL DOSES YOUR FACILITY WAS APPROVED TO RECEIVE.

VFC Office Use Only 
   RECEIVED: 
  PROCESSED: 
  FOLLOW UP: 
  1st ORDER: 
  2nd ORDER: 
  3rd ORDER: 
  COMPLETED: 

Call (800) 282-8672 if you have any questons regardng ths form.

PLEASE FAX YOUR ORDER TO: (800) 318-0810