Please Submit Your VFC Certificates of Completion

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2025 VFC Provider SafeVax Confirmation Form

"*" indicates required fields

The three staff members identified in your ImmuNet profile will need to confirm that they have completed 2025 VFC provider training by submitting their certificates of completion. Please submit certificates for the "Provider Development" training for your responsible medical provider, primary VFC contact, and back up VFC contact(s). If you have questions, please email us at mdh.izinfo@maryland.gov.

VFC Pin Number*

Office / Practice Name*

Name of Responsible Medical Provider*

First Last

Certificates of Completion*

Please upload one Certificate of Completion for the Responsible Medical Provider

Drop files here or

Max. file size: 20 MB.

Name of Primary VFC Contact Person*

First Last

Certificates of Completion*

Please upload one Certificate of Completion for the Primary VFC Contact Person

Drop files here or

Max. file size: 20 MB.

Name of Back-up VFC Contact Person*

First Last

Certificates of Completion*

Please upload one Certificate of Completion for the Back-up VFC Contact Person

Drop files here or

Max. file size: 20 MB.

Name of 2nd Back-up VFC Contact

First Last

Certificates of Completion

Please upload one Certificate of Completion for the Back-up VFC Contact Person(s)

Drop files here or

Max. file size: 20 MB.

Name of person completing this form*

Email*

Office / Practice Phone*

Maryland Vaccines for Children Program

Submit Certificates of Completion

Please Submit Your VFC Certificates of Completion

2025 VFC Provider SafeVax Confirmation Form

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