Forms
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PDF [205KB]Request for Medical Exemption from Vaccinations PDF [205KB]Form 139-M
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PDF [164KB]Request for Religious Exemption from Vaccinations PDF [164KB]Form 139-R
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PDF [62KB]Non-Viable Vaccine Returns PDF [62KB]Providers: Should this vaccine be returned or disposed? Check this document.
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Vaccine Wastage and Disposed Form
Form 132. Please complete this Wastage and Disposed form for any vaccine that is wasted and disposed of by vaccine providers.
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Vaccine Return Form
Form 131. Please complete this Vaccine Return Form for any vaccine eligible for return by vaccine providers.
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PDF [170KB]Vaccine Borrowing Report PDF [170KB]Form 1122
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PDF [297KB]Temperature Log for Refrigerator PDF [297KB]Form 670
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PDF [252KB]Temperature Log for Freezer PDF [252KB]Form 670F
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Mississippi State Department of Health • 570 East Woodrow Wilson Dr • Jackson, MS 39216 • 866‑HLTHY4U • Contact and information
