TPH COVID-19 Vaccine Immunization Program Enrollment Request Form for Health Care Providers

All Health Care Providers (including physicians and nurse practitioners) who wish to order COVID-19 Vaccines from Toronto Public Health must be enrolled into the program prior to ordering. All of your answers are private and confidential.

Please only submit this form once for every Health Care Provider (one physician/nurse practitioner per site) that is enrolling.

If you have any question about the program or this form, please email COVIDVaccineOrder@toronto.ca.

*Site Name

Registered Ontario Government Site Name

Contact Name

*Site Address

Site Address (E.g. 100 Main Street)

Unit/Suite/Floor (E.g. Unit 601, 6th Floor)

City

Postal Code

Telephone Number

*Email

Confirm email address

Hours of Business
(E.g. Monday-Friday 9:00AM - 5:00PM)

*Practice Type

Primary Care Provider (i.e. Family Doctor, Nurse Practitioner Led Clinic)

General Pediatrician

Hospital or Hospital Satellite

Other, please specify

*Service Model (as defined by the Ontario Ministry of Health)

Program Eligibility

Primary Health Care Providers must meet all eligibility criteria below in order to enroll and order COVID-19 Vaccines from Toronto Public Health. If you do not have one of the below criteria, a member of our team will reach out to you directly by email.

*General Facility Criteria

I am a Health Care Provider (including physicians and nurse practitioners) working in Toronto.

My practice is registered to store publically funded vaccines. All vaccines ordered will be given free of charge to eligible Ontario clients.

*Does your practice have a valid Ontario Government Pharmaceutical and Medical Supply Services (OGPMSS) Client Number?

Yes, please specify:

*Has the fridge where vaccines will be stored been inspected by Toronto Public Health within the 12 months with a 'pass' result?

Yes

*Do all vaccinators at this site/facility have a COVaxON account where Toronto Public Health is the Authorizing Organization to document COVID-19 vaccine administration and wastage?

Yes

*Vaccine Storage and Handling Criteria

My facility/site is compliant with the Ontario Ministry of Health Vaccine Storage and Handling Guidelines:
- Vaccine refrigerator maintains temperatures between +2℃ to +8℃
- Vaccine refrigerator temperatures are monitored twice daily and documented

The site/facility will maintain a strict inventory of the vaccine, including doses received, unused, spoiled, expired and wasted.

The site/facility will keep vaccines in a secure location.

Once the site/facility has received the COVID-19 vaccines from the distributor, the site/facility is responsible for the storage and handling of the COVID-19 vaccine, as per the Ontario Ministry of Health COVID-19: Vaccine Storage and Handling Guidelines.

Physical COVID-19 vaccine transfers between sites/facilities are not recommended by Toronto Public Health in accordance with the Ontario Ministry of Health Vaccine Storage and Handling Guidelines.

Should sites/facilities deem that a transfer is required in an exceptional circumstance, both the site/facility that is sending the vaccine and the Site/Facility that is receiving it are responsible for following vaccine storage and handling guidelines during the transfer. Once the vaccine has been received, that site/facility becomes responsible for the storage and handling of the COVID-19 vaccine.

*COVaxON Criteria

All authorized COVaxON users will have read and agreed to comply with the COVaxON Acceptable Use Policy.

All vaccinators will document vaccine administration on COVaxON within 48h of administering.

All vaccinators will report wastage events in COVaxON within 48h of occurrence

The site/facility will promptly report any breach or suspected breach of privacy to Toronto Public Health at COVIDVaccineOrder@toronto.ca.

The site/facility will not resell, distribute, damage, or provide unnecessary access to COVaxON.

*Clinical Criteria

At the time of vaccine administration, the site/facility will have obtained and documented informed consent for all individuals who will be receiving the vaccine.

At the time of vaccine administration, the site/facility will ensure that only personnel who are legally authorized to administer vaccines, administer the COVID-19 vaccine.

The site/facility has plans in place to monitor recipients of the vaccine for adverse reactions, as per Ministry requirements.

The site/facility will report any adverse events using the Report of Adverse Events Following Immunization (AEFI) form and fax the completed form to 416-696-3492 or email to AEFI@toronto.ca.

*Vaccine Administration Criteria

The site/facility will ensure that the vaccine is administered in accordance with all applicable laws, Ministry of Health directions and guidelines

The site/facility have reviewed the manufacturer's instructions for administering the vaccine.

Doses will be administered according to the Ontario Ministry of Health recommendations

Once the vaccine has arrived on site, the site/facility will administer all doses of the vaccine within the manufacturer's required time frame.

To prevent vaccine wastage, the site/facility will only request a 1-2 week vaccine supply per order.

To prevent vaccine wastage, the site/facility will have a plan to use up vaccine orders within its post-thaw viability.

Please check the box below to proceed.

When you click on the Finish button below, you will be submitting an enrollment request for your site.

Health Care Providers should not submit more than one enrollment request per site.