Health and Seniors Care

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

Client ID/Holding Point Code:

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

Health region

Organization or facility name

Type of organization

Delivery Address

Street number

Street name

PO Box/RR

City or town

Postal code

Site Vaccine Coordinator/Liaison information

Contact name

Email address

Phone

Fax

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: Site will administer vaccine same day of delivery (no storage required) Site will administer vaccine within 1 week of delivery

Client Screening

What system will be used for checking client/patient immunization:

Data Entry

Please confirm plans for data entry (e.g., vaccine doses administered) Site staff will be responsible for PHIMS data entry within 24 hours of vaccine administration Alternative mechanism for data entry (e.g., partnering with FIT or Public Health) who will be responsible for entering PHIMS data within 2 business days

Checklist

Vaccine Rescue Plan Yes No

Vaccine administrators (immunizers) have completed required training Yes No

Site has a system in place for checking client/patient immunization history Yes No

Site has a process in place for immunization data entry Yes No

Site has a process in place to ensure staff have adequate training in PHIMS Yes No

Site has an anaphylaxis management protocol/plan and staff are trained to administer epinephrine (staff have recent BLS/CPR) Yes No

Authorization

Date:

Name:

Position:

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

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