Monkeypox (MPX) Vaccination Provider Enrollment

Storage and Handling Training

Yes

No (Training Link will be provided when selected.)

Storage and Handling Training Certificate Upload

Upload certificates for Vaccine Coordinator, Backup Coordinator and anyone else that will be handling vaccine.

Drop your files here

Organizational Legal Name

Number of Locations for Organization

Organizational Phone Number

Phone

Organizational Email

Please do not use the same email throughout this document unless the person serves both roles.

Organization Street Address 1

Organization Street Address 2

Organization City

Organization County

Organization State

Organization Zip Code

Chief Medical Officer Information

Chief Medical Officer Last Name

Chief Medical Officer First Name

Organization CMO Middle Initial

Organization CMO Title

Organization CMO licensure state

Organization CMO licensure number

Organization CMO Phone number

Phone

CMO Email Address

The CMO will receive the completed Provider Agreement at this email address for signature via DocuSign. Please do not use the same email in for all signatures unless the person serves in multiple roles.

Organization CMO Street Address

Organization CMO Street Address 2

Organization CMO City

Organization CMO County

Organization CMO State

Organization CMO ZipCode

Monkeypox Vaccination Provider Agreement

Provider Profile Information

Individual Facility Location

Location Name

Will another location order for this facility?

Contact information for location's primary vaccination coordinator

The vaccine coordinator and backup coordinator must be different people and have different email addresses.

Vaccine Coordinator Last Name

Vaccine Coordinator and Back-Up Coordinator must be different people.

Vaccine Coordinator First Name

Vaccine Coordinator and Back-Up Coordinator must be different people.

Vaccine Coordinators Middle Initial

Vaccine Coordinator Phone Number

Phone

Vaccine Coordinator Email

The Vaccine Coordinator will receive the completed Provider Agreement for signature at this email address via DocuSign. Please do not use the same email in for all signatures unless, the person serves both roles. Vaccine Coordinator and Back-Up Coordinator must be different people.

Contact Information for location's backup vaccination coordinator

Vaccine Backup Coordinator Last Name

Vaccine Coordinator and Back-Up Coordinator must be different people.

Vaccine Backup Vaccine Coordinator First Name

Vaccine Coordinator and Back-Up Coordinator must be different people.

Vaccine Backup Coordinator Middle Initial

Vaccine Backup Coordinator Phone Number

Phone

Vaccine Backup Coordinator Email Address

The Backup Vaccine Coordinator will receive the completed Provider Agreement for signature at this email address via DocuSign. Please do not use the same email in for all signatures unless, the person serves both roles. Vaccine Coordinator and Back-Up Coordinator must be different people. Please do not use the same email throughout this document. Vaccine Coordinator and Back-Up Coordinator must be different people.

Location for Vaccine Shipment

Location Address for shipment of Vaccines Street 1

Location Address for shipment of Vaccines Street 2

Location City for shippment of Vaccines

Location County for Shipment of Vaccines

Location State for Shipment of Vaccines

Location shipment Zipcode

Location Shipment Phone Number

Phone

Location Shipment Fax Number

Phone

Location where Vaccine will be administered. (If different from receiving location)

Location Administration Street 1

Location Administration Street 2

Location Administration City

Location Administration County

Location Administration State

Location Administration Zipcode

Location Administration Phone Number

Phone

Location Administration Fax Number

Phone

Shipping Times

Days and times vaccine coordinators are available for receipt of vaccine shipments. Please list all times in military time. ex: 08:00-11:59 (am with no spaces) 12:00-16:00 (pm with no spaces) Please leave blank if you are not available. *Helpful hint- Shipping times must have 4 consecutive hours of availability, other than Mondays.

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Vaccination provider type for this location

Select the number that corresponds with your facility:

1- Commercial vaccination service provider

2-Corrections/detention health services

3- Health center- community (non-FQHC/non-RHC)

4- Health center- migrant or refugee

5- Health center- occupational

6- Health center- STD/HIV clinic

7- Health center - student

8- Home health care provider

9- Hospital

10- Indian Health Service

11- Tribal Health

12- Medical practice - family medicine

13- Medical practice - pediatrics

14- Medical practice - internal medicine

15- Medical practice - OB/GYN

16 -Medical practice - other specialty

17- Pharmacy - chain

18- Pharmacy - Independent

19- Public health provider - public health clinic

20-Public health provider - FQHC

21- Public health provider - Rural Health Clinic

22- Long-term Care - federally certified

23- Long-term Care- non-federally certified

24- Long-term Care- assisted living

25- Long-term Care- intellectual or developmental disability

26- Long-term Care- combination (in the same facility)

27- Urgent Care

28- Other

Location Type (Select One Number)

Setting(s) where this location will administer vaccine

Select all that apply

Childcare setting

College, Technical school, or University

Community center

Correctional/detention facility

Healthcare provider office (outpatient)

Hospital (inpatient)

In home

Long-term care facility

Pharmacy

Health Department

School (K-grade 12)

Shelter

Temporary or offsite vaccination clinic- (POD)

Temporary location - mobile clinic

Urgent care

Workplace

Other

Population(s) served by this location

Select all that apply

General pediatric population

General Adult Population

Adults 65 years or older

Long Term Care Facility

Healthcare workers

Critical infrastructure/essential workers

Military-active duty

Military- veteran

Homeless

Pregnant women

Racial and ethnic minority groups

Tribal communities

People who are incarcerated/detained

People living in rural communities

People who are underinsured or unisured

People with disabilities

People who are at high risk for Monkeypox

Other Populations

Does your organization currently report vaccine administration data to the jurisdiction's IIS ?

Does your location report to IIS? (MIIX)

Estimated number of 1-dose vials your location can store

Use these estimations on your ability to store during peak vaccination periods (e.g., during back-to-school or influenza season).

Refrigerated

Frozen

Storage unit details for this location

List brand/model/type of storage units to be used for storing vaccine at this location:

1 Brand/Model/Type of Cold Storage

1 DDL Brand and Serial # for the above unit

2 DDL Brand and Serial # for the above unit

3 DDL Brand and Serial # for the above unit

Providers Practing at this facility

List below all licensed healthcare providers at this location who have PRESCRIBING authority (i.e., MD, DO, NP, PA, RPh). If you have more than 5 providers please go the MSDH website and fill out the last page of the provider agreement and submit to MSDH office of Immunizations.

1 Provider Name

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