Influenza Vaccine Availability Tracking System: Reporting Form

* indicates required field

I have the authority to report for my company.*

Enrolled in IVATS?*

Contact Information

Name*

First Last

Company name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email*

Enter Email Confirm Email

Is your company a wholesale distributor or manufacturer licensed to sell influenza vaccines?*

Does your company have influenza vaccine for sale that is in stock?*

Please indicate the ways that a healthcare provider may order your vaccine. Check all that apply and be sure to enter the required information.*

Phone

Email

Fax

Website

Other

Please indicate the availability of the following influenza vaccines from your company. Check box if the vaccine is in stock. Check all that apply.*

Comments or additional information

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