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 |