2018 317 Agreement to Participate-Nevada State Immunization Program
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Immunization Program 4150 Technology Way Suite 210 Carson City Nevada 89706
317 Program
March 2018 March 2019 Agreement to Participate
________________________________________________________ ______________
Facility Name NSIP PIN
Physical/Shipping Address: __________________________________________________________________________
Street Address (NO P.O. Box) Suite City State Zip
Mailing Address: __________________________________________________________________________________
(May be the same as shipping) Suite City State Zip
Front Office Phone: ( ) Fax: ( ) _____
Primary Vaccine Coordinator:
( )
First Name
Last Name
Back-Up Vaccine Coordinator or Supervisor:
( )
First Name
Last Name
Mailing Address (if different from above):
Street/PO Box
IMPORTANT Days and times the clinic is open to accept delivery of vaccines; at minimum, must be open at
least 4 consecutive hours on a weekday other than Monday:
Day Of The Week
Time Office Open for Delivery
Closed for LUNCH from/to
Time Office Closes
Notify the Nevada State Immunization Program (in writing) of any changes, i.e. clinic closures or changes in hours of operation.
2018 317 Agreement to Participate-Nevada State Immunization Program
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To receive publicly funded vaccines at no cost I agree to the following conditions, on behalf of myself and all the
nurses, and others associated with the healthcare facility of which I am the medical director,
practice administrator or
Medical Director, practice administrator or equivalent (one who is authorized to prescribe vaccines under
Nevada State Law) to initial all:
______1) 317-funded vaccine can only be administered to uninsured or underinsured adults aged 19 years and older.
Any children aged birth 18 years that meet these criteria are eligible for the Vaccines for Children (VFC)
Program and should not receive 317-funded vaccine and should instead receive VFC vaccine.
a) Uninsured: An adult who has no health insurance coverage;
b) Underinsured: An adult who is covered by public or private health insurance but the coverage does
not include vaccines or does not cover all Advisory Committee on Immunization Practices (ACIP)
recommended vaccines. The patient would be eligible to receive any vaccines no covered by their
health insurance plan.
Exceptions to this 317 Rule include:
Hepatitis B birth dose vaccine;
Influenza vaccines used in Point of Dispensing (POD) exercises; and
Vaccines needed to respond to a documented disease outbreak.
______2) I will comply with the most current immunization schedules, dosages and contraindications that are
established by the ACIP and included in the 317 Program, unless:
a) In the provider’s medical judgment, and in accordance with accepted medical practice, the provider
deems such compliance to be medically inappropriate (NRS 392.439, 394.194, 432A.250); or
b) The particular requirements contradict state law, including laws pertaining to religious exemptions
(NRS 392.437, 394.193, 432A.240).
______3) I will maintain all records related to the 317 Program for a minimum of three (3) years and will make these
records available to public health officials, including the Nevada Department of Health & Human Services
and/or the U.S. Department of Health & Human Services, upon request.
______4) I will immunize all eligible individuals with 317-funded vaccine at no charge to the patient for the vaccine.
______5) For uninsured and underinsured adults, the administration fee charged should not exceed the regional
Medicare vaccine administration fee of $21.34 per vaccine dose administered.
______6) I will not deny administration of a federal or state-supplied vaccine to an established patient because the
individual is unable to pay the vaccine administration fee.
______7) I will distribute the most current Vaccine Information Statement (VIS) each time a vaccine is administered
and will maintain records in accordance with the National Childhood Vaccine Injury Compensation Act
(NCVIA), which includes reporting clinically significant adverse events to the Vaccine Adverse Event
Reporting System (VAERS).
______8) I will comply with the requirements for vaccine management and accountability, including:
a) Ordering vaccine and maintaining appropriate vaccine inventories;
b) Not storing vaccine in “dorm-style” refrigerators at any time;
c) Storing vaccine under proper conditions at all times. Refrigerator and freezer vaccine storage units
and temperature monitoring equipment and practices must meet Nevada State Immunization Program
d) Return all eligible, publicly-supplied spoiled/expired vaccine to CDC’s centralized distributor within
six (6) months of spoilage/expiration.
2018 317 Agreement to Participate-Nevada State Immunization Program
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______9) I agree to use the continuous digital monitoring devices provided by the NSIP to monitor vaccine storage
units containing federal- and/or state-supplied vaccines. The NSIP will provide at least two (2) LogTag
TRED30-7R continuous monitoring devices with capabilities of alarming for out-of-range temperatures,
provides current temperatures and minimum/maximum temperatures, low battery indicator, accuracy of
+/- 1°F (0.5°C), has memory storage capacity of at least 4,000 readings, used in conjunction with a
detachable biosafe glycol-encased probe and comes with current certificates of calibration accredited by an
ILAC MRA signatory body or meets ISO/IEC 17025 international standards. I understand it is the clinic’s
responsibility to pay for the biennial recalibration of the data loggers. If I cannot use the digital
monitoring devices supplied by the NSIP, then I agree to use a NSIP-approved alternative. I agree to return
all equipment supplied to my office through federal or state funds to the NSIP upon termination of this
_____10) I agree to purchase at least one (1) backup digital monitoring device (data logger) with a valid and current
certificate of calibration accredited by an ILAC MRA signatory body or meets ISO/IEC 17025
international standards, capable of alarming (visually or audibly) for out-of-range temperatures, provides
current temperatures and minimum/maximum temperatures, low battery indicator, accuracy of +/- 1°F
(0.5°C), used in conjunction with a detachable biosafe glycol-encased probe and have it readily available
to ensure that twice a day temperature assessment and recording can be performed in the event the NSIP-
supplied data logger is no longer working or has been sent out for recalibration.
_____11) In the event the NSIP Program Manager, Vaccine Manager, Provider Quality Assurance Manager, and/or
the Vaccine Storage & Handling Coordinator recommends to my Primary or Backup Vaccine Coordinator
and/or myself, the Medical Director, that I purchase a stand-alone refrigerator and/or freezer unit as a
result of reviewing long-term continuous temperature monitoring data, and the office does not purchase the
recommended storage unit type, then I WILL BE HELD ACCOUNTABLE for replacing all 317-
funded vaccine doses (at private cost) that are spoiled or wasted as a result of temperature
excursions in the non-recommended unit.
_____12) I will maintain clients’ immunization records for a period specified by NRS 629.051 “Health care records:
Retention; disclosure to patients concerning destruction of records; exceptions; regulations. #1: …Each
provider of health care shall retain the health care records of his or her patients as part of his or her
regularly maintained records for 5 years after…their receipt or production. Health care records may be
retained in written form, or by microfilm or any other recognized form of size reduction, including,
without limitation, microfiche, computer disc, magnetic tape, and optical disc…Health care records may
be created, authenticated and stored in a computer system which limits access to those records. #7: A
provider of health care shall not destroy the health care records of a person who is less than 23 years of
age on the date of the proposed destruction of the records. The health care records of a person who has
attained the age of 23 years may be destroyed in accordance with this section for those records which
have been retained for at least 5 years or for any longer period provided by federal law. If requested, I
will make such records available to the Nevada Department of Health & Human Services and/or the U.S.
Department of Health & Human Services. I will make such records available to the health authority and/or
their designee, if requested (per NAC 441A.750). This includes the collection of data for quality
improvement assessments.
_____13) I will record all vaccines that our office administers to children and adults into Nevada’s immunization
information system, NV WebIZ, unless the patient has chosen not to participate. In order for a patient to
opt-out of NV WebIZ, a form must be completed and sent to the NV WebIZ Help Desk. Providers with an
undue hardship (i.e., no internet access) can comply by completing a NV WebIZ paper reporting form and
mailing to the NV WebIZ Program. Please contact the NV WebIZ Help Desk to obtain this form. These
requirements are in reference to Nevada Revised Statute (NRS) and corresponding Nevada Administrative
Code (NAC) R094-09A. View these laws at:
NRS: http://www.leg.state.nv.us/NRS/NRS-439.html#NRS439Sec265
NAC: http://leg.state.nv.us/NAC/NAC-439.html#NAC439Sec870
NV WebIZ: http://dpbh.nv.gov/Programs/WebIZ/WebIZ_-_Home/
2018 317 Agreement to Participate-Nevada State Immunization Program
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_____14) I agree to have all staff who enter data into NV WebIZ receive the appropriate training prior to obtaining a
username, password, entering data, or receiving vaccine (new enrollees). I also agree to have the Primary
and Back-up VFC coordinators complete ‘Inventory management and Reconciliation” training prior to
being able to order 317 vaccine. I understand my clinic cannot be enrolled in the 317 program until these
classes have been completed by these individuals.
_____15) I agree to purchase a standalone freezer-less refrigerator, and separate freezer if applicable, if I am
enrolling in the 317 Program for the first time or if I open a new office location. I understand that I
cannot use a combination style refrigerator/freezer or “Dorm Style” refrigerator to store federally
or state funded vaccine.
_____16) I agree to notify the Nevada State Immunization Program of all changes immediately as they occur
including, but not limited to:
Change of shipping/mailing address;
Change in vaccine shipping hours;
Change of Primary or Back-Up Vaccine Coordinators;
Change of telephone, fax number or contact e-mail;
Additions/deletions of physicians, PA’s and nurse practitioners to the provider site.
_____17) I will not move/transport publicly supplied vaccines unless I have prior approval from the Nevada State
Immunization Program.
_____18) I (the facility) will be held financially responsible for the dose-for-dose replacement cost of any publicly
supplied vaccines that are wasted through my failure or the failure of my staff to properly store, handle,
account for, or rotate the vaccines. Furthermore, replacement doses must be administered only to 317
eligible individuals.
_____19) I will not borrow 317-funded vaccine to administer to non-317 eligible patient(s) unless a rare, unplanned
situation exists. In the event an unplanned situation occurs that requires borrowing of 317-funded vaccine
to administer to a non-317 eligible patient, or vice-versa, then I will be required to complete the “NSIP
Vaccine Borrowing Report” to document the borrowed and replaced doses. I will submit this form with
monthly reports for the month in which the borrowing occurs.
Explanation of each item listed above is outlined in the “317 Program Protocol March 2018.” Protocol can
be found at: http://dpbh.nv.gov/Programs/VFC/dta/Forms/Vaccines_for_Children_(VFC)_Program_-_Forms/
By signing this form, I certify on behalf of myself and all immunization providers in this facility, that I have read
and agree to the 317 enrollment requirements listed above and understand that I am accountable for compliance
with all requirements.
Printed Name: Medical Director or equivalent Medical License #
(One who is authorized to prescribe vaccines under Nevada State Law)
Signature: Medical Director or equivalent Date
click to sign
click to edit
2018 317 Agreement to Participate-Nevada State Immunization Program
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Print the full names (including middle initial), title and licensing information of all, but only, those providers who
possess a
medical license and prescription writing privileges who write prescriptions for the “state supplied” vaccines.
It is not necessary to include the names of all staff within this facility that may administer vaccine, but rather only
those who possess a medical license or are authorized to write prescriptions.
Hospitals need only submit information listed below on the current Physician in Chief. Entire hospital staff lists
are not required.
(i.e. MD,
DO, etc.)
(Attach another sheet if additional space is needed)