| Last Name | First Name | DOB (mm/dd/yyyy) | Sex | Street Address | City | State | Zipcode | FL County Of Residence | Phone Number | Race | Ethnicity | Date Given (mm/dd/yyyy) | Vaccine | Manufacturer | Lot Number | NDC | Vaccine Exp. Date (mm/yyyy or mm/dd/yyyy) | VIS Pub Date (mm/dd/yyyy) | Inj Site | Inj Route | Eligibility | Risk Factors | Given By Name | Given by Credentials | #FLShots Version Nbr: 03/02/2021 1# |
| PATIENT INFORMATION | ||
| LAST NAME | Verify spelling and any punctuation. | |
| FIRST NAME | Verify spelling and any punctuation. | |
| DOB | Enter the date of birth in the month/day/4-digit year format. Ex. February 14, 1995 = 02/14/1995; Do not format cells to mimic this requirement - it will "break" the spreadsheet. | |
| SEX | Enter "Male" as M; Enter "Female" as F; Enter "Unknown" as U | |
| STREET ADDRESS/CITY | Please verify all information is current. | |
| STATE | FL - all other states, please see the "States" tab for those abbreviations. | |
| ZIP CODE | Zip Code can be either the 5 or 9 digit zip code. An embedded dash is not required, but may be used. | |
| COUNTY OF RESIDENCE | See "Counties" tab for an alphabetical list of all Florida counties. For counties in states other than Florida, use OUT-OF-STATE | |
| PHONE NUMBER | ** | When provided, must include the area code. Formatting (parentheses, dash) is optional. Extensions are not permitted. |
| RACE | ** | See the "Races" tab for a complete list; Use the abbreviation given exactly as it is written or it will not be accepted. |
| ETHNICITY | Attention: This is now required. Enter "HISPANIC OR HAITIAN ORIGIN" as Y; Enter "NOT HISPANIC OR HAITIAN ORIGIN" as N; Enter "UNKNOWN" as U |
| State codes | ||
| NAME | ABBREV | |
| Enter the ABBREV | ALABAMA | AL |
| ALASKA | AK | |
| ARIZONA | AZ | |
| ARKANSAS | AR | |
| CALIFORNIA | CA | |
| COLORADO | CO | |
| CONNECTICUT | CT | |
| DELAWARE | DE | |
| DISTRICT OF COLUMBIA | DC | |
| FLORIDA | FL | |
| GEORGIA | GA | |
| GUAM | GU | |
| HAWAII | HI | |
| IDAHO | ID | |
| ILLINOIS | IL | |
| INDIANA | IN | |
| IOWA | IA | |
| KANSAS | KS | |
| KENTUCKY | KY | |
| LOUISIANA | LA | |
| MAINE | ME | |
| MARYLAND | MD | |
| MASSACHUSETTS | MA | |
| MICHIGAN | MI | |
| MINNESOTA | MN | |
| MISSISSIPPI | MS | |
| MISSOURI | MO | |
| MONTANA | MT | |
| NEBRASKA | NE | |
| NEVADA | NV | |
| NEW HAMPSHIRE | NH | |
| NEW JERSEY | NJ | |
| NEW MEXICO | NM | |
| NEW YORK | NY | |
| NORTH CAROLINA | NC | |
| NORTH DAKOTA | ND | |
| OHIO | OH | |
| OKLAHOMA | OK | |
| OREGON | OR | |
| PENNSYLVANIA | PA | |
| PUERTO RICO | PR | |
| RHODE ISLAND | RI | |
| SOUTH CAROLINA | SC | |
| SOUTH DAKOTA | SD | |
| TENNESSEE | TN | |
| TEXAS | TX | |
| UTAH | UT | |
| VERMONT | VT | |
| VIRGIN ISLANDS | VI | |
| VIRGINIA | VA | |
| WASHINGTON | WA | |
| WEST VIRGINIA | WV | |
| WISCONSIN | WI | |
| WYOMING | WY |
| County codes | |||
| FLORIDA | OTHER | ||
| ALACHUA | OUT-OF-STATE | ||
| BAKER | |||
| BAY | |||
| BRADFORD | |||
| BREVARD | |||
| BROWARD | |||
| CALHOUN | |||
| CHARLOTTE | |||
| CITRUS | |||
| CLAY | |||
| COLLIER | |||
| COLUMBIA | |||
| DADE | |||
| DESOTO | |||
| DIXIE | |||
| DUVAL | |||
| ESCAMBIA | |||
| FLAGLER | |||
| FRANKLIN | |||
| GADSDEN | |||
| GILCHRIST | |||
| GLADES | |||
| GULF | |||
| HAMILTON | |||
| HARDEE | |||
| HENDRY | |||
| HERNANDO | |||
| HIGHLANDS | |||
| HILLSBOROUGH | |||
| HOLMES | |||
| INDIAN RIVER | |||
| JACKSON | |||
| JEFFERSON | |||
| LAFAYETTE | |||
| LAKE | |||
| LEE | |||
| LEON | |||
| LEVY | |||
| LIBERTY | |||
| MADISON | |||
| MANATEE | |||
| MARION | |||
| MARTIN | |||
| MONROE | |||
| NASSAU | |||
| OKALOOSA | |||
| OKEECHOBEE | |||
| ORANGE | |||
| OSCEOLA | |||
| PALM BEACH | |||
| PASCO | |||
| PINELLAS | |||
| POLK | |||
| PUTNAM | |||
| SANTA ROSA | |||
| SARASOTA | |||
| SEMINOLE | |||
| ST. JOHNS | |||
| ST. LUCIE | |||
| SUMTER | |||
| SUWANNEE | |||
| TAYLOR | |||
| UNION | |||
| UNKNOWN | |||
| VOLUSIA | |||
| WAKULLA | |||
| WALTON | |||
| WASHINGTON |
| Races | ||
| NAME | ABBREV | |
| Enter the ABBREV | AMERICAN INDIAN/ALASKAN | AMINDIAN |
| ASIAN INDIAN | ASIANIND | |
| BLACK/AFRICAN AMERICAN | BLACK | |
| CHINESE | CHINESE | |
| FILIPINO | FILIPINO | |
| GUAMANIAN/CHARMORRO | GUAM | |
| HAWAIIAN | HAWAIIAN | |
| JAPANESE | JAPANESE | |
| KOREAN | KOREAN | |
| OTHER ASIAN | ASIANOTH | |
| OTHER NONWHITE | OTHER | |
| OTHER PACIFIC ISLANDER | PACOTHER | |
| SAMOAN | SAMOAN | |
| UNKNOWN | UNKNOWN | |
| VIETNAMESE | VIETNAMESE | |
| WHITE | WHITE |
| Please enter one of the following into the "Ethnicity" column. | |||||
| IF THE ETHNICITY IS: | ENTER: | ||||
| Hispanic or Haitian origin | Y | ||||
| NOT Hispanic or Haitian origin | N | ||||
| Unknown | U |
| Vaccines | |
| NAME | |
| Enter the NAME | COVID-19 JANSSEN |
| COVID-19 MODERNA | |
| COVID-19 PFIZER | |
| COVID-19 UNK |
| Vaccine Mfgs | ||
| NAME | ABBREV | |
| Enter the ABBREV | JANSSEN | JSN |
| MODERNA US, INC. | MOD | |
| PFIZER, INC | PFR |
| Injection Sites | ||
| Description | ABBREV | |
| Enter the ABBREV | LEFT ARM | LA |
| LEFT DELTOID | LD | |
| LEFT GLUTEOUS MEDIUS | LG | |
| LEFT LOWER FOREARM | LLFA | |
| LEFT THIGH | LT | |
| LEFT VASTUS LATERALIS | LVL | |
| RIGHT ARM | RA | |
| RIGHT DELTOID | RD | |
| RIGHT GLUTEOUS MEDIUS | RG | |
| RIGHT LATERAL THIGH | RLT | |
| RIGHT LOWER FOREARM | RLFA | |
| RIGHT THIGH | RT | |
| RIGHT VASTUS LATERALIS | RVL |
| Injection Routes | ||
| Description | ABBREV | |
| Enter the ABBREV | INTRADERMAL | ID |
| INTRAMUSCULAR | IM | |
| INTRAVENOUS | IV | |
| PERCUTANEOUS | PCT | |
| SUBCUTANEOUS | SC | |
| TRANSDERMAL | TRD |
| Eligibilities | ||
| Description | ABBREV | |
| Enter the ABBREV | COVID-19 NON-VFC PRIVATELY INSURED | FLSHOTS071 |
| COVID-19 NON-VFC UNDERINSURED | FLSHOTS072 | |
| COVID-19 NON-VFC UNINSURED | FLSHOTS073 | |
| COVID-19 UNSPECIFIED ELIGIBILITY | FLSHOTS074 |
| Risk Factors | |||
| NAME OF FACTOR | When entering more than one, separate the values with a semi-colon (;) | ||
| AGE 65+ (EXCLUDING LTCF) | |||
| FIREFIGHTER | |||
| HEALTH CARE PERSONNEL | |||
| LAW ENFORCEMENT | |||
| LTCF RESIDENT | |||
| LTCF STAFF | |||
| PHYSICIAN ORDERED | |||
| SCHOOL EMPLOYEE | |||
| UNKNOWN | |||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |