Request for Vaccinia (Smallpox) Vaccine Form (see reverse for instructions) Section 1: Physician Details Physician MI FIRST Email LAST Clinic Number & Suite/ Phone Name Street Bldg# Postal City ST Country Fax Code The undersigned certifies that the vaccine will be administered only by individuals under his/her supervision. Physician’s Signature_______________________________________________________________________________ Date ___________________ Section 2: Laboratory Details PI MI FIRST Email LAST Clinic Number & Suite/ Phone Name Street Bldg# Postal City ST Country Fax Code Virus(es) involved: _______________________________________________________ Used in development of/study of: _____________________________________________ Rec’d FOR BN _________________________________________________________________________________________________________________________________________________ INTERNAL USE ONLY ID# Section 3: Recipient Details Indication Category (at least one box must be checked) Name Age Position/Duties (1) Reseacher (2) LRN activities (3) First Responder Please return completed forms to CDC Drug Service, 1600 Clifton Rd, MS D-09, Atlanta, GA 30333 phone: (404) 639-3670 fax: (404) 639-3717 email: [email protected] Revised 4/2008 Instructions: Request for Vaccinia (Smallpox) Vaccine The Centers for Disease Control & Prevention (CDC) distributes vaccinia vaccine to physicians for immunization of laboratory personnel who require vaccination due to occupational risks. The vaccine must be administered under the supervision of a licensed physician. In order for us to supply you with the vaccine, we require the completion of this form. The form must be returned along with a copy of the physician’s Curriculum Vitae (CV) and medical license to the CDC Drug Service (either by mail, email, or fax). Instructions for completion: □ Section 1: Please provide the name of the physician who will be responsible for overseeing the administration of vaccinia vaccine to recipients at your site. A complete physical address is needed for shipment. o PHYSICIAN CREDENTIALS: A resume' or curriculum vitae of the responsible physician is required, along with a copy of his/her current medical license or certification. □ Section 2: When applicable, include the name of the principle investigator, or head of the laboratory, for which the research is being conducted under. We would like a statement regarding the research which necessitates the use of the vaccine, including the types of virus(es) involved. □ Section 3: List the name, age, position (e.g. research associate, virologist, etc.) and duties which could potentially cause exposure of this individual to the virus used in their occupation. Refer to ACIP’s recommendations regarding vaccinia vaccination found: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5010a1.htm Select from one of the three indication categories: (1) Researcher: laboratory workers who directly handle a) cultures or b) animals contaminated or infected with, nonhighly attenuated vaccinia virus, recombinant vaccinia viruses derived from nonhighly attenuated vaccinia strains, or other Orthopoxviruses that infect humans (e.g., monkeypox, cowpox, vaccinia, and variola) (2) LRN activities: laboratory workers who process and test potentially high-risk samples, as required by their Laboratory Response Network (LRN) membership (3) First Responder: medical personnel assigned to a state’s bioterrorism response team If more space is needed, attach extra sheets. Each potential vaccinee must be reported to the CDC Drug Service using this form prior to vaccination. Once we receive the completed forms we will expedite shipment of the vaccine to you. We do not routinely distribute vaccinia immune globulin. However, a supply is available and will be provided should a need for it arise. Please contact the CDC Drug Service staff at 404-639-3670 if you have additional questions. Revised 4/2008 .