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2020 UNinsured Female Veterans Report

Reporting Vaccine Services to UNinsured Female Veterans


Reporting Vaccine Services to UNinsured Female Veterans


Welcome to the Texas Department of State Health Services (DSHS) Immunization Unit online survey to report the number of uninsured female veterans that received vaccine at your facility.

In accordance with Senate Bill 805 from the 85th Texas Legislature, Regular Session, DSHS must collect and report the number of uninsured female veterans who receive Adult Safety Net (ASN) vaccines at your facility.

Tips for gathering data for the survey:

  • Every uninsured adult patient that receives a dose of ASN vaccine from your facility is required to fill out an adult eligibility screening form (F11-12842) (paper or electronically). The newest version of this form (revised 2/18) collects the gender of the patient along with veteran status.
  • You and your staff can select the best way to manage these documents in your clinic.
  • By the 5th of each month, using the eligibility forms, you must enter the number of female veterans who received ASN vaccine in your facility.
  • If there were no female veterans who received ASN vaccine in your facility for the previous month, you must report 0.

Thank you for your continued participation in the ASN Program.

 If you have any questions, please contact us via email at or call 512-776-6244.