Independent Immunization Partners Channel (IIPC) Application Form

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INSTRUCTIONS:
Please ensure you read the program requirements as outlined in the IIPC program guide prior to completing this registration form. Please only submit one application per location. If you have any questions while filling out the application, please email: independentimmunizationpartners@gov.mb.ca.

General Information

Note: this is the 5-digit number your location uses to order publicly funded vaccines through the Provincial Distribution Warehouse).



Delivery Address



Site Vaccine Coordinator/Liaison information

Program Eligibility Criteria for Partners

Please refer to the Independent Immunization Partners Channel Program Guideline for requirements.


Vaccine Storage & Monitoring

Please select which category your site falls under:
Please confirm your vaccine storage plans


Client Screening



Data Entry

Please confirm plans for data entry (e.g., vaccine doses administered)
Is a plan in place for ensuring all necessary staff have completed PHIMS training?


Checklist

Vaccine Rescue Plan
Vaccine administrators (immunizers) have completed required training
Site has a system in place for checking client/patient immunization history
Site has a process in place for immunization data entry
Site has a process in place to ensure staff have adequate training in PHIMS
Site has an anaphylaxis management protocol/plan and staff are trained to administer epinephrine (staff have recent BLS/CPR)

Authorization

Upon receipt of your application, a member of the IIPC team will follow up to discuss the status of your application and next steps.