Vaccine Request and Eligibility Form

Vaccine Request and Eligibility Form

JYNNEOS vaccine is distributed by San Bernardino County Department of Public Health (SBC DPH) in accordance with SBC DPH Policies and Procedures. If you are a new JYNNEOS vaccine provider, in order to receive JYNNEOS vaccine, this application must be completed in its entirety. Attachments required for application submission include: 1) photo of vaccine storage unit AND 2) a valid certificate of calibration for the digital data logger that will record vaccine temperatures. If you are eligible for the program, a representative from the San Bernardino County Department of Public Health (SBC DPH) will contact you.

Please utilize this form if you are previously approved to receive JYNNEOS vaccines and are requesting additional supply. You will not be required to resubmit storage information.

Facility Information

COVID ID*

If not applicable, please enter N/A

Organization Name*

Facility Street Address*

Facility Zip Code*

Facility City*

Other (Facility Type)

Point of Contact Information

Point of Contact First & Last Name*

Point of Contact Title*

Point of Contact Phone Number*

Phone

Point of Contact Email Address*

Will you be the point of contact (POC) the day of the delivery?*

The POC is the person who will be on site to physically receive the vaccine from the couriers.

Yes

Receiving POC First & Last Name*

Receiving POC Phone Number*

Phone

Receiving POC Email Address*

Vaccine Request

JYNNEOS Vaccine

Two (2) dose series, four (4) weeks apart
Please review storage and handling information
Allow the vaccine to thaw and reach room temperature before use. Once thawed, the vaccine may be kept at +2°C to +8°C (+36°F to +46°F) for up to 8 weeks. Do not refreeze.
5-dose vial if administering intradermally (preferred method for individuals ≥ 18 years who do not have a history of keloid scars)
Single dose vial if administering subcutaneously (for individuals < 18 years or ≥ 18 years with a history of keloid scars)

Purpose of vaccine*

Pre-exposure prophylaxis (PrEP)

Post-exposure prophylaxis (PEP)

Other

Please indicate the # of JYNNEOS doses your facility is requesting.*

Please submit your request in increments of 5.

Will the requested doses be administered via intradermal or subcutaneous injection (select all that apply)?*

The U.S. Food and Drug Administration has issued an emergency use authorization (EUA) for the JYNNEOS vaccine to allow healthcare providers to use the vaccine by intradermal injection for individuals 18 years of age and older who are determined to be at high risk for monkeypox infection.

Intradermal (preferred method for individuals ≥18 years who do not have a history of keloid scars)

Subcutaneous

If you have indicated doses are for subcutaneous method, please provide a brief justification (for example: staff untrained in intradermal injection, do not have access to proper syringes, patients with history of keloid scars, etc.)*

By what date do you need the vaccine?*

Delivery or Pick-up

A representative will be in contact with you to determine the appropriate method based on resources available

Select or enter value

Provider Screening

Have you previously received JYNNEOS vaccine?*

Yes

Provider Information

National Provider Identifier (NPI)

Provider Name*

Medical License Number:*

Volume of MSM Patients Seen by Provider Per Year

Select or enter value

Number of Suspected Monkeypox Patients

Patients in care who currently have 1) a characteristic rash AND 2) high clinical suspicion for monkeypox

Does this facility have an active myCAvax account?

Select or enter value

Vaccine Storage Units

Indicate your refrigerator storage unit types below. Dormitory-Style units are NOT acceptable for the storage of vaccines. “Dormitory-style” units are defined as small combination refrigerator/freezer units with a single external door and two internal compartments (a refrigerator and a freezer compartment) within the same unit.

Please see JYNNEOS storage conditions for more information.

Stand alone refrigerator

Commercial/pharmacy grade

What is your available capacity to store frozen JYNNEOS (by vial)?*

Temperature range for JYNNEOS storage: -25°C to -15°C or (-13°F to +5°F)

What is your available capacity to store refrigerated JYNNEOS (by vial)?

Temperature range for JYNNEOS storage: 2C° to 8°C (36°F and 46°F)

What is the make and model of the storage unit?

File Attachments*

Please submit images of the following: 1) vaccine storage unit AND 2) Certificate of Calibration for the digital data logger that records vaccine temperatures.

Drag and drop files here or

Please submit a brief description (2-3 sentences) describing your plan to vaccinate priority populations, including those who may be uninsured or underinsured.*

Please include any additional important details or notes.

Compliance

A representative will be in contact with you.

I acknowledge the following:

Immunizers are trained and working under supervision of a medical provider.
All the doses administered will be documented in the California Immunization Registry (CAIR). Either direct entry or through a spreadsheet to be provided by CDS.
Any adverse health events experienced by Monkeypox vaccines that occur within 4 weeks of immunization and require medical attention are reported promptly to https://vaers.hhs.gov/ (VAERS).
Proper storage units and a calibrated digital data logger (DDL) is maintained.
A record which includes the patient's name, age category, manufacturer, lot number and expiration date is retained.
My facility is in compliance with the CDC Monkeypox Vaccination Program Provider Agreement
The answers provided on this form are accurate.

Please check box if you agree to the above acknowledgment.*

Send me a copy of my responses

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