Public Health Department Resource Order Form

Date: Organization:
Name: Address:
City: State:   Zip:
Phone: Fax:

Please order the number of packages needed: English Spanish
Record Cards Adult Record Card (50)  
Pink USIR (cards may be ordered individually) (250)  
Lifetime Personal Record (Yellow Card) (50)  
Schedule Cards Adolescent (100)
Adult (100)
Childhood (100)
Childhood 8.5 x 11 (50)
Other Materials Pertussis Cards Surround your Baby double-sided English/Spanish
(100)
 
Pertussis Cards Surround your Loved Ones double-sided
English/Spanish (100)
 
Pertussis Tear Pads Surround your Baby double-sided
English/Spanish (100)
 
Pertussis Tear Pads Surround your Loved Ones double-sided
English/Spanish (100)
 
Pertussis Tear Pad Stands (limit 2)  
Bookmarks - Adult Immunization/You Never Outgrow Vaccinations
double-sided English/Spanish (50)
 
Perinatal Hepatitis B Lab Testing Form - 2010 version
(individual forms)
 
International Certificate of Vaccination (ICV)  
Plastic Sleeves for ICV (100)  
Plastic Sleeves (100)  
Next Due Stickers (250 per pad)  
PPV Stickers (500 per roll)  
VFC Stickers (100 per roll)  
Exemption Forms Personal  
Religious  
Posters Adult Immunization/You Never Outgrow Vaccinations 11 x 17
Adult Schedule Poster 11 x 17
Got Vaxed Poster Question Mark 14 x 20  
Got Vaxed Poster Teenagers 14 x 20  
Get the Flu Vaccine Poster 11 x 17
Pertussis Surround your Baby 11 x 17
Pertussis Surround your Loved Ones 11 x 17
Preteen Doctor Visit 12 x 20
Vaccinate Before you Graduate 11 x 17  
Hepatitis B Vaccine Initiative
Providers ONLY NEW
Hepatitis B Vaccine Initiative Flyer Generic
Hepatitis B Vaccine Initiative Flyer-Salt Lake Co.
Hepatitis B Vaccine Initiative Flyer-Utah Co.
Hepatitis B Vaccine Initiative Flyer-Weber/Morgan Co.
Brochures Get the Flu Vaccine (50)
Hepatitis A What You Should Know (50)
Older Adults Need Shots (100)
Planning a Trip (100)  
Preteen Doctor Visit (100)
Protect Yourself Adult (100)
The Utah School Immunization Rule (100)
Vaccinate Before you Graduate (100)
Vaccine Safety (50)
Tearpads VFC Information Tearpad double-sided English/Spanish (50)  
Please verify your order by entering the random letters (case sensitive) displayed in this image:

Contact Lisa Young with any questions (801) 538-9101. Include quantities that will be sufficient for a three month period.
PLEASE ALLOW 2-3 WEEKS FOR DELIVERY