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Adult Influenza Vaccine Initiative Enrollment

Welcome to the Texas Department of State Health Services (DSHS) Adult Influenza Vaccine Initiative Enrollment

DSHS requires all enrolling sites to complete this Program Agreement Enrollment Form. Required fields are marked with an *.

Prior to starting your enrollment, gather the following information:

  • ImmTrac2 Org Code: If your site does not have an Org Code you must register with ImmTrac2 to receive one. Information regarding ImmTrac2 Org Code may be found on the ImmTrac2 webpage www.dshs.texas.gov/immunize/immtrac.
  • Facility name, address, phone, and fax.
  • Signing Clinician's name, title, email, medical license number and NPI.
  • Primary and Back-up Vaccine Coordinator's name and emails.
  • Training Requirements: Before completing this agreement, DSHS requires that your Primary and Back-up Vaccine Coordinators complete the following:
    • You Call the Shots Module 10, Vaccine Storage & Handling, available at www.cdc.gov/vaccines/ed/youcalltheshots.html
    • Once the module is completed, it is important to save copies of the Certificates of Completion as PDF files. You will be prompted to upload these certificates as you progress through the enrollment agreement.
  • List of all practitioners at your site with prescribing authority to include name, title, medical license number and NPI.
  • The number of patients you have seen in the previous 12 months or number of personnel you have in your facility under the following categories. This information can be collected from your doses administered data, Medicaid claims, encounter data, billing system, or staff/patient roster.
    • Healthcare Practitioners & Personnel
    • Pregnant Women
    • First Responders
    • High Risk Adults 19+
    • Healthy Adults 19-64
    • Healthy Adults 65+
  • Number of refrigerators and freezers that contain flu vaccine.
  • Number of data loggers, including a backup, that monitor the temperatures of the refrigerators and freezers.
  • Facilities that are a Federally Qualified Health Center (FQHC) and a Rural Health Center (RHC) must also submit a copy of the Centers for Medicare & Medicaid Services (CMS) letter designating the sites as such.



Tips for completing the DSHS Adult Influenza Vaccine Initiative Enrollment Agreement:

  • Ensure that the latest version of your web browser is installed. Certain portions of the form may not function unless your web browser is up to date.
  • Do not use the web page back arrow button at the top left of your screen when filling out this document. It is important to go to the bottom of the page to use the PURPLE "BACK" button.
                                                                       
  • Users will receive an alert message for select questions when the field is incomplete (no data entered). To clear the alert message, users must enter data in the notated field. Until the selected field has been completed (data entered), users cannot continue on to the next page of the survey. 
                                              
  • If you need to gather data and continue your survey at a later time, go all the way to the bottom of the page to find the grey bar with "Save and Continue Later" link. If you leave the survey without selecting "Save and Continue Later", all of your data will be lost and you'll have to start again. By selecting "Save and Continue Later", you will be asked to enter an email address and a unique link will be sent to that email address which will give you an opportunity to continue the survey where you left off.     
                                          
                                                                                                                                                                                                              
                                                            

Thank you for your interest in the Adult Influenza Vaccine Initiative. We look forward to having you as a member of our team!

If you have any questions, please contact us via email to AdultFluProgram@dsh.texas.gov or call (800) 252-9152.