Application for Oregon Yellow Fever (YF) Vaccine Certification and Stamp Approval

Application for Oregon Yellow Fever (YF) Vaccine Certification and Stamp Approval

Thank you for your interest in Oregon’s Yellow Fever (YF) Program. Please complete and submit this application to certify as an Oregon YF provider, register your practice site(s), and receive designated stamp(s).

Approval of this application certifies you to provide YF vaccine at up to three Oregon registered sites and receive one stamp for each site. Only registered sites are eligible to receive YF vaccine products. If you would like to register additional administration sites, contact us @ yellowfever.vaccine@odhsoha.oregon.gov

Application Process

1. Complete the required CDC Yellow Fever Vaccine: Information for Health Care Professionals Advising Travelers Course, CDC Train.

2. Complete this application in full, upload the CDC YF Course Completion Certificate, acknowledge YF requirements, and submit application.

3. Re-certify as an Oregon YF provider every three years. You will be notified 15 and 30 days prior to renewal. Failure to renew voids eligibility to participate in Oregon’s YF Program.

For more information: Oregon's Yellow Fever Program and Application FAQs

Confirm Application Type*

Select

CDC Yellow Fever Training Certificate*

You are required to complete this training and upload the completion certificate in PDF format. CDC Yellow Fever Vaccine: Information for Health Care Professionals Advising Travelers Course, CDC Train.

Questions specifically about the training? Contact a member of the CDC TRAIN Learner Support team

Drag and drop files here or

Provider Eligibility*

Stamps are issued to credentialed health care providers eligible to provide vaccine in Oregon.

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License Number*

Provide your license number. Licensure must be currently active to receive certification.

Full Name*

Provide your full name as it appears on your license and licensing credentials (MD, DO, etc.).

Primary Practice Site Name*

If your primary practice site is part of a chain, please provide the store number.

If you do not have a primary site location number, please enter "N/A".

Do you administer YF vaccine at this site to patients less than 18 years old?*

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Primary Address*

Stamp will be mailed to this address. Signature required upon receipt.

City*

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Zip Code*

County*

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Phone Number*

Phone

Provider Organization Email*

Do you administer YF vaccine at more than one site?*

Select

Secondary Practice Site Name*

If this practice site is a multistore chain pharmacy (like Costco, Fred Meyer)? Please include the store number with each address

Do you administer YF vaccine at this site to those that are less than 18 years old?*

Select

Secondary Address*

Please only provide addresses that will be receiving YF Vaccine through the mail.

Secondary City*

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Secondary Zip Code*

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Secondary Phone Number*

Phone

Do you administer YF vaccine at a third location?*

Select

Third Practice Site Name*

If this practice site is a multistore chain pharmacy (like Costco, Fred Meyer)? Please include the store number with each address

Do you administer YF vaccine at this site to patients less than 18 years old?*

Select

Third Address*

Please only provide addresses that will be receiving YF Vaccine through the mail.

Third City*

Select

Third Zip Code*

Select

Third Phone Number*

Phone

Acknowledgement for Yellow Fever Vaccination Certification

Oregon yellow fever vaccine provider acknowledgements and requirements*

• The yellow fever stamp is issued for authentication of International Certificates of Vaccination or Prophylaxis (ICVP). The stamp holder is fully knowledgeable concerning the procedures necessary for issuing a valid ICVP document: Instructions for completing the ICVP

• The health care provider signing the ICVP may be the stamp owner, or another health care provider authorized by the stamp holder to administer or supervise the administration of the vaccine.

• The CDC Yellow Book: Health Information for International Travel is a resource for those providing care to international travelers

• The stamp holder, or designate, is fully knowledgably of yellow fever vaccine storage, refrigeration, handling, and proper administration. Yellow fever vaccine product information can be found in the package insert.

• The ALERT Immunization Information System (IIS) is used to check vaccine history and to forecast what vaccines are due for the patient. Once the vaccine is administered, patient and vaccine dose information must be entered in the ALERT Immunization Information System (IIS) within 14 days of administration.

Information on enrolling in ALERT IIS is found here.

• The stamp holder will notify OHA of any change in their registered yellow fever administration site(s).

• The stamp holder will notify OHA if no longer providing YF vaccine. Reach out to yellowfever.vaccine@odhsoha.oregon.gov for instructions on returning the YF stamp.

• Reports of any serious vaccine adverse events must be made promptly to the Vaccine Adverse Events Reporting System (VAERS)

• Oregon Health Authority (OHA) maintains authority over the stamp and can revoke the stamp or privileges at its discretion.

Signature*

Your typed full name is recognition of submission of this application and acknowledgement of Oregon yellow fever vaccine provider requirements.

Date of Application*

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