Kentucky Vaccine Program Forms

For questions regarding KVP forms please contact:
Judy Baker at (502) 564-4478, ext. 3518;
Clarissa Wilson at (502) 564-4478, ext. 3734; or
Rita Lathrem at (502) 564-4478, ext. 3914.

Private Provider Forms

If your PIN begins with D, OP, CC, FQ, or RH use the following forms:

• Instructions for Private Provider Order Form
• Private Provider Vaccine Order and Eligibility Worksheet
• Instructions for Private Provider Activity Worksheet
• Private Provider Vaccine Activity Worksheet

Health Department Forms

If your PIN begins with H use the following forms:

• Instructions for Health Department Order Form
• Health Department Vaccine Order and Eligibility Form

Hospital Forms

If your PIN begins with 100 or 200 use the following forms:

• Instructions for Hospital Order Form
• Hospital Vaccine Order and Eligibility Worksheet
• Hospital Vaccine Activity Worksheet
  

All Providers

The following forms are for all providers:

Return and Adjustment Forms

• Vaccine Return and Adjustment Form
• What Not to Return to McKesson

Temperature Charts

• Fahrenheit Temperature Log 1-15
• Fahrenheit Temperature Log 16-31
  
• Celsius Temperature Log 1-15
• Celsius Temperature Log 16-31

Storage Troubleshooting Record

• Vaccine Storage Troubleshooting Record