Immunization Registry Form (Internal VDH Employees)

Immunization Registry Team Contact

Use this form to make a request or report concerns in the Vermont Immunization Registry. This form is only intended for internal (VDH) employees, please do not share it with external partners/practices.
Your Name

First NameLast Name
Today's Date

MonthDayYear
Date
IMR Team Only
Please leave blank
Your Email
example@example.com
Your Phone
Please enter a valid phone number.Format: (000) 000-0000.
District Office
(or, write in Central Office)
How can our team help?
Forecaster and Evaluated History
What vaccine(s) are you seeing the issue for
i.e. Covid, Hep A, DTP, etc.
Is this in reference to a specific patient?
Patient name as it appears in the Registry

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
While it is possible there is an issue in a Patient's Evaluated History and the resulting forecaster recommendations, often the issue is related to documentation error, i.e. a mistake was made when entering a vaccine.

Before you continue, please review the code guidance sheets below.
The best practice is to match the CVX code in the graph to the CVX code displayed after the vaccine name in the evaluated history:
Does the CVX code displayed in the Registry match the vaccine in the code guidance sheet?
The logic built into the backend of the evaluated history and forecaster is complex. While a vaccine may fall outside of the standard schedule, there are "absolute minimum/maximum" limits that will still result in a "Valid" evaluation.

The links below bring you to the latest available guidance for routine vaccination shedules. These links are subject to change frequently, but we will do our best to keep them up to date.
- Child Immunization Schedule Notes
- Adult Immunization Schedule Notes
Please review the vaccine in question to make sure what you are seeing does not fall into a "Special Situation" scenario.
Does the issue fall outside of the absolute minimum/maximum range?
HL7 Messaging
Practice/Facility Name
Contact at the Practice

First NameLast Name
Contact's Email
We may reach out to the contact directly as needed
The Immunization Registry team cannot view or make changes to a specific practices Electronic Health Record (EHR), so the first step to evaluating an issue with automatic (HL7) messaging is to have the practice reach out to their EHR Vendor (such as Epic).
Login Issues
Individual experiencing login troubles

First NameLast Name
Individual's email
example@example.com
Best phone number to contact them
Please enter a valid phone number.Format: (000) 000-0000.
Have they already submitted a confidentiality agreement?
- Health Care and Licensed Child Care Provider Confidentiality Agreement
- School User Confidentiality Agreement
Tech Troubleshooting (not including login)
Duplicate Patients
Incorrect name to be merged

First NameLast Name
VIS Issues
What is the issue you are seeing with the VIS
If you are not seeing a VIS, it is possible you may have selected the incorrect vaccine in the Registry.

Before you continue, please review the code guidance sheets below.
The best practice is to match the CVX code in the graph to the CVX code displayed after the vaccine name in the evaluated history:
Does the CVX code displayed in the Registry match the vaccine in the code guidance sheet?
Shots should never be saved in the Registry before a VIS is selected, as our system currently does not allow for users to go back in and make this change. A ticket will need to be submitted to make this change. Please enter the patient information below.
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
Date
Vaccine Name
Vaccination Date

MonthDayYear
Date
Which VIS needs to be added to the record?
Data Requests
Practice Name
PIN
Vaccine(s)

Other
Date range start

MonthDayYear
Date
Date range end

MonthDayYear
Date
Filter age(s) by
DOB range start

MonthDayYear
Date
DOB range end

MonthDayYear
Date
Lower age range end
Upper age range end
Write in
Be as specific as possible
Request/report a training
Type of Practice
Site/Facility
PIN
Primary contact name
Primary contact email
example@example.com
Primary contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Role(s) of individual(s)
Additional Trainee(s) - Optional
Additional Trainee Email
example@example.com
Add additional emails here, if needed
Date of Training

MonthDayYear
Date
Duration
Minutes
Training Mode
Type of Training
IMR Function(s)

Other
Notes
Follow-up needed by IMR team?
Are there date(s)/time(s) that work better for the facility?
Something Else
Please upload a screenshot of what you are seeing

use the snipping tool to add a screenshot of the issue
Cancelof
and/or please describe the issue
Be as detailed as possible
It looks like this requires action on your part or the part of the practice. Please complete the related follow-up to see if the issue persists before continuing.

Immunization Registry Team Contact

Forecaster and Evaluated History

HL7 Messaging

Login Issues

Tech Troubleshooting (not including login)

Duplicate Patients

VIS Issues

Data Requests

Request/report a training

Something Else