Semi-Annual Report of Doses Administered to Uninsured and Underinsured Adults (UUAV Program)

Clinics selected to administer MDH vaccine to uninsured and underinsured adults age 19 years and older must submit a report of the number of doses administered.

This report is due twice a year and covers the six-month period preceding the report due date. Reporting for April 1 - September 30 is normally due Novemebr 30 but is due February 14, 2014 this time. Reporting for October 1 - March 31 is still due on May 31.

Orders may be held until providers have submitted this report.

Note: If you are a satellite clinic you don't need to complete this report, your parent clinic will submit a report. Satellite clinics receive vaccine from a parent clinic and the MnVFC PIN contains a letter (e.g., 00032A).
Clinic Information
Clinic name:
Telephone number:
Person completing form:

Reporting for:
April 1, 2013 - September 30, 2013 (due February 14, 2014)
October 1, 2013 - March 31, 2014 (due May 31, 2014)

Report of Doses Administered to Uninsured and Underinsured Adults
Doses Administered
Hepatitis A (HepA: Havrix)
Hepatitis B (HepB: Engerix-B, Recombivax HB)
Human papillomavirus (HPV2, HPV4: Cervarix, Gardasil)
Influenza (all presentations)
Meningococcal (MCV4: Menactra, Menveo)
Measles, mumps, rubella (MMR: MMRII)
Pneumococcal (PPSV23: Pneumovax)
Tetanus, diphtheria (Td: Generic, Tenivac)
Tetanus, diphtheria, pertussis (Tdap: Adacel, Boostrix)
Varicella (Var: Varivax)
Zoster (Zostavax)

Tip: You may want to consider working with your regional MIIC staff or local public health agency for suggestions on how to collect data for semi-annual reports. Call 651-201-5522 or 1-800-657-3970 for more information.

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