Forms and Publications - Adult Safety Net Program

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) 08/2016
F11-14143 Adult Safety Net (ASN) Provider Enrollment Form (PDF) 08/2016
Adult Biological Order Form (PDF)

ASN Program Provider Manual

Texas Vaccines for Children Provider Manual
Section Title Revision Date
Introduction Introduction to the 2017 Adult Safety Net (ASN) Provider Manual (PDF) 05/2017
Chapter 1 Provider Eligibility and Enrollment (PDF) 05/2017
Chapter 2 Patient Eligibility and Screening (PDF) 05/2017
Chapter 3 Vaccine Management (PDF) 05/2017
Chapter 4 Billing and Administration (PDF) 05/2017
Chapter 5 Program Evaluation (PDF) 05/2017
Chapter 6 Fraud and Abuse (PDF) 05/2017
Chapter 7 Documentation Requirements (PDF) 05/2017
Chapter 8 Vaccine Information Statements (VIS) (PDF) 05/2017
Chapter 9 Ordering Forms and Literature (PDF) 05/2017
Chapter 10 Immunization Resources (PDF) 05/2017
Full Manual Adult Safety Net Program - Provider Manual (PDF) 05/2017

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. 

2017 Adult Site Visit Reviewer Guide

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

ASN Follow-Up Plan

ASN Interim Site Visit Communication

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 October 16, 2017