Patient Eligibility of Screening Record 
Adult HPV Immunization Program 


Date:________________ 

Patient:________________________________________________________________________ 
                Last Name              First Name                           MI 

Date of Birth:________________ 

Provider:_______________________________________________________________________ 


A record must be kept in the healthcare provider’s office that reflects the status 
of patients who received immunization through the AHPV. The record may be completed 
by the patient or by the healthcare provider. The same record may be used for all 
subsequent visits as long as the patient’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 receiving vaccine. 


This patient qualifies for vaccination through the AHPV because she 
(check all that apply): 
                             
(a) is 19 years of age through 26 years of age; AND 
    Date:_____ Date:_____ Date:_____ Date:_____ 
         _____      _____      _____      _____

(b) does not have health insurance; OR
    Date:_____ Date:_____ Date:_____ Date:_____ 
         _____      _____      _____      _____

(c) has health insurance that DOES NOT pay for vaccines
    Date:_____ Date:_____ Date:_____ Date:_____ 
         _____      _____      _____      _____




If you have any questions regarding the completion of this form, 
please call 1-800-282-8672.