COVID-19 Vaccine Transfer Request Form

To transfer COVID 19 Vaccine you must submit a request to your COVID Immunization Nurse Representative by completing this form.

Transferring Facility Name*

TransferringFacilityCounty*

Select

Transferring Facility COVID-19 PIN*

Select or enter value

Person Completing Form*

Title*

Phone #*

Phone

Email*

Date of Transfer*

Receiving Facility Name*

Receiving Facility COVID-19 PIN*

Select

Name of person Receiving the Vaccine*

Phone # of person receiving the vaccine*

Phone

Email of person recieiving the vaccine*

Vaccine Name and NDC*

Moderna Bivalent 6mo+ - MDV5 - 80777-0282-99

Moderna Bivalent 6m-5y - MDV2 - 80777-0283-99

Pfizer Bivalent 12y+ (gray) - MDV6 - 59267-0304-02

Pfizer Bivalent 12y+ SDV (gray) - SDV - 59267-1404-02

Pfizer Bivalent 5y-11y (orange) - MDV10 - 59267-0565-02

Pfizer Bivalent 6mo-4y (maroon) - MDV10 - 59267-0609-02

Novavax - MDV5 - 80631-0102-10

Number of Doses*

Lot Number*

Expiration Date*

Additional Vaccine to Transfer?*

Select

2. Vaccine Name and NDC*

Moderna - MDV10 - 80777-0273-99

Moderna - MDV14 - 80777-0273-98

Pfizer (purple) - MDV6 - 195 pack - 59267-1000-02

Pfizer (purple) - MDV6 - 25 pack - 59267-1000-03

Pfizer (gray) - MDV6 - 10 Pack - 59267-1025-04

Pfizer Pediatric (orange) - MDV10- 10pack- 59267-1055-04

Janssen (J&J) MDV5 - 59676-0580-15

Moderna Bivalent: NDC 80777-282-99 50ug/0.5ml

Pfizer Bivalent: NDC 59267-1404-2 30ug/0.3ml

2. Number of Doses*

2. Lot Number*

2. Expiration Date*

Do you have a 3rd Vaccine to Transfer?*

Select or enter value

3. Vaccine Name and NDC*

Moderna - MDV10 - 80777-0273-99

Moderna - MDV14 - 80777-0273-98

Pfizer (purple) - MDV6 - 195 pack - 59267-1000-02

Pfizer (purple) - MDV6 - 25 pack - 59267-1000-03

Pfizer (gray) - MDV6 - 10 Pack - 59267-1025-04

Pfizer Pediatric (orange) - MDV10- 10pack- 59267-1055-04

Janssen (J&J) MDV5 - 59676-0580-15

Moderna Bivalent: NDC 80777-282-99 50ug/0.5ml

Pfizer Bivalent: NDC 59267-1404-2 30ug/0.3ml

3. Number of Doses*

3. Lot Number*

3. Expiration Date*

Do you have a 4th Vaccine to Transfer?*

Select or enter value

4. Vaccine Name and NDC*

Moderna - MDV10 - 80777-0273-99

Moderna - MDV14 - 80777-0273-98

Pfizer (purple) - MDV6 - 195 pack - 59267-1000-02

Pfizer (purple) - MDV6 - 25 pack - 59267-1000-03

Pfizer (gray) - MDV6 - 10 Pack - 59267-1025-04

Pfizer Pediatric (orange) - MDV10- 10pack- 59267-1055-04

Janssen (J&J) MDV5 - 59676-0580-15

Moderna Bivalent: NDC 80777-282-99 50ug/0.5ml

Pfizer Bivalent: NDC 59267-1404-2 30ug/0.3ml

4. Number of Doses*

4. Lot Number*

4. Expiration Date*

Do you have a 5th Vaccine to Transfer?*

Select

5. Vaccine Name and NDC*

Select

5. Number of Doses*

5. Lot Number*

5. Expiration Date*

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