Immunization Materials - Pennsylvania Department Of Health
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1
2IMMUNIZATION MATERIALS
Ordered by:
Name:
___________________________________________________________________________________
Organization: ___________________________________________________________________________________
Address:
___________________________________________________________________________________
___________________________________________________________________________________
City:
___________________________________________ State: ________ Zip: _______________
Phone #:
___________________________________________________________
(include ext #)
Requestor Status/Ordering limits:
Citizen/Personal Use – one order per month, limited to 50 pieces per title
□
College/University – limited to 500 pieces per month
□
Corporate/Business – limited to 500 pieces per month
□
Criminal Justice (Adult or Juvenile) – limited to 500 pieces per month
□
Hospital/Medical Center/Clinic – limited to 500 pieces per month
□
Legislative – limited to 1,000 pieces per month
□
Physician/Doctor’s Office – limited to 500 pieces per month
□
Police/Local Government - unlimited
□
School Districts – limited to 500 pieces per month
□
The Department, with justification, may waive these limits.
Complete the entire form and mail to:
OR
Fax #: 717-214-7223
PA Department of Health
Phone #: 717-787-5681
Division of Immunizations
Attn: Patti Kolva
Email:
pkolva@pa.gov
Room 1026, Health & Welfare Bldg
625 Forster Street
Harrisburg, PA 17120
To place an order, please put the quantity needed in the far right column. Order by units of 50.
If you have any questions regarding the materials listed above, please contact Patti Kolva,
PA Department of Health, Division of Immunizations, at (717) 787-5681 or by email at
pkolva@pa.gov
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