Wisconsin DHS

(Updated 03/01/2021 to highlight the provider registration scenarios that help while filling out required Form B and Redistribution Forms.)

Background

The Wisconsin COVID-19 Vaccine program is enrolling entities that wish to vaccinate. By enrolling in the program, entities and their vaccinators will be approved to administer COVID-19 vaccine in Wisconsin. To become a COVID-19 Vaccinator, all organizations must have an approved Form A and Form B. To redistribute vaccine, all enrolled COVID-19 vaccinators must also have an approved Redistribution Form.

Steps to complete enrollment and redistribution forms

It is important that you complete every step in the enrollment process in order to ensure your submission is processed as quickly as possible. Please use Google Chrome when navigating the enrollment tool. Email(link sends e-mail) us if you have any questions!

Step 1: Log in to the COVID-19 Vaccine Enrollment Tool(link is external) using your Department of Administration (DOA)/Wisconsin Logon Management System username and password.

• If you do not have a DOA/Wisconsin Logon, please register here(link is external).
  • Select Self-Registration. After you accept the user agreement and fill in your personal profile information, select “DHS Health Reports” under “Systems You Will Access.”
  • After your registration is complete, proceed to the enrollment tool(link is external).
• If you have a DOA/Wisconsin Logon, then proceed to the enrollment tool(link is external) and logon using your DOA/Wisconsin Logon username and password.

Step 2: Generate your forms.

USE CAUTION: Once information is entered and site type is chosen, you may NOT go back to change them.

• Enter information into the COVID-19 Vaccine Enrollment Tool.
• Scroll to the bottom of the page and select “Generate Forms”, which will generate forms specifically for your organization.
  • Your organization name and a reference number will be pre-populated on the forms (located at the bottom of each generated form).
  • You can have your vaccine sites use this information to ensure they are using your organization-specific forms.

Step 3: Complete and sign your forms. (Updated 03/01/21)

Note: All signatures must be present on a form before submission. Instruction is provided within the forms by hovering over the blue bars in the form.

• Each unique legal organization must complete a Form A.
• If your organization may need to move vaccine to another organization, or to another Form B location within your own organization, you must complete a Redistribution Form. This form should match your organization’s Form A in the following fields:
  • Organization Name
  • Medical Director/Chief Medical Officer
  • Chief Executive Officer (CEO) or Chief Financial Officer (CFO)
• Complete a Form B for each physical address where you will store or administer COVID-19 vaccine, with certain exceptions. Please see these provider registration scenarios to see what forms are required for different vaccination clinics. If you have questions about whether your organization requires additional Form B submissions, please email us(link sends e-mail).

Step 4: Submit all your forms.

Note: You may submit your organization's forms from any DOA/Wisconsin Logon Management System login. Only submit the completed forms that were specifically generated for your organization with the reference number in step 2 above (this is listed at the bottom right of your generated forms).

• Find “Submit Forms” at the top left of your web browser.
• Upload your completed and signed forms to their corresponding fields. DON’T FORGET TO HAVE YOUR FORMS SIGNED AND DATED!
• Scroll to the bottom of the page and select the “Upload Files” button.
• If you need to change your information after submitting do so via the Wisconsin Immunization Registry. Any information that needs to be changed outside of WIR can be done by contacting dhscovidvaccinator@wi.gov(link sends e-mail).

Step 5: At various different stages of registration, staff may contact you to ask questions about your submission, correct errors, or provide instructions on next steps. Please respond to this outreach immediately so that we can continue processing your registration. This step may occur after your organization has been approved to receive vaccine.

Step 6: Once your information is verified and your WIR account is configured, the primary contact listed on the Form B will receive an email from DHS with next steps for your organization.

 Your vaccine coordinator, back-up coordinator, and other relevant staff must complete the required Wisconsin Immunization Registry (WIR) and vaccine storage and handling trainings. These training videos do not use Adobe Flash Player. You will be emailed a survey to attest that your staff have completed the WIR and the Storage and Handling trainings. Your organization will not be able to order COVID-19 vaccine unless these trainings are completed and acknowledged within 5 days of receipt of the email with the attestation survey.

 We also highly recommend your staff takes the CDC's Just in Time trainings for Pfizer-BioNTech(link is external) and Moderna(link is external) vaccines! See the Trainings section below for additional trainings.