Forms
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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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Non-Viable Vaccine Returns
Providers: Should this vaccine be returned or disposed? Check this document.
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Vaccine Borrowing Report
Form 1122
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Request for Medical Exemption from Vaccination
Form 139
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Temperature Log for Refrigerator
Form 670
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Temperature Log for Freezer
Form 670F
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Mississippi State Department of Health • 570 East Woodrow Wilson Dr • Jackson, MS 39216 • 866-HLTHY4U • Contact and information
