Forms and Publications - Adult Safety Net Program

Reporting Vaccine Services to UNinsured Female Veterans

Table of Contents

Also see the Texas Vaccines for Children Program Forms and Publications page for other documents related to the Adult Safety Net Program.

Printed copies of Adult Safety Net publications may be ordered and shipped to your location at no charge to you via the Immunization Unit Online Order Form.

Screening and Enrollment Forms

Adult Safety Net Program Forms and Publications
Publication # Title Revision Date
F11-12842 Adult Safety Net (ASN) Patient Eligibility Screening Form Bilingual (PDF) 09/2021
Online Form
Provider Agreement Form NA
Adult Biological Order Form (PDF)

ASN Program Provider Manual

Texas Vaccines for Children and Adult Safety Net Provider Manual
Publication #
Title Revision Date
2021 TVFC and ASN Provider Manual 2021

ASN Vaccine Management Plan Templates

Vaccine Management Plan Templates
Publication # TitleRevision Date
 E11-14498TVFC and ASN Program Vaccine Management Plan Templates (PDF)11/2021

ASN Promotional Materials

Adult Safety Net Program Forms and Publications
Publication # Title Revision Date
11-14202 “Adults Need Vaccine Too” Adult Safety Net (ASN) Program Brochure - Bilingual (PDF) 01/2016
11-14202P “Adults Need Vaccine Too” Adult Safety Net (ASN) Program Poster - Bilingual (PDF) 10/2015
E11-14564 Adult Safety Net (ASN) Program Provider Flyer - Bilingual (PDF) 06/2015

Adult Site Visit Reviewer Guide

The reviewer guide below will be used to conduct site visits to healthcare providers enrolled in the Adult Safety Net Program and for special projects with healthcare providers providing immunization services to adults. 

2021 Adult Site Visit Reviewer Tool

ASN Compliance Site Visit Acknowledgement of Receipt (PDF)- This form is to be used for sites with PINs

ASN Follow-Up Plan

Adult Immunization Standards, Schedules, & Recommendations

The following resources are based on recommendations from the Advisory Committee on Immunization Practices (ACIP) and/or the National Vaccine Advisory Committee (NVAC).

Note: All adult health-care providers (including ASN Program providers, non-ASN Program adult immunization providers, and even non-immunizing adult providers) should refer to the Centers for Disease Control and Preparedness (CDC) Standards for Adult Immunization Practice.
Last updated November 24, 2021