Forms

• Vaccine Storage Troubleshooting Record
• Temperature Log for Refrigerator
• Temperature Log for Freezer
• PDF [2MB] 
  Vaccine Administration Record PDF [2MB] 
  912e
• PDF [205KB] 
  Request for Medical Exemption from Vaccinations PDF [205KB] 
  Form 139-M
• PDF [164KB] 
  Request for Religious Exemption from Vaccinations PDF [164KB] 
  Form 139-R
• PDF [62KB] 
  Non-Viable Vaccine Returns PDF [62KB] 
  Providers: Should this vaccine be returned or disposed? Check this document.
• Vaccine Return Form
  Form 131. Please complete this Vaccine Return Form for any vaccine eligible for return by vaccine providers.
• PDF [170KB] 
  Vaccine Borrowing Report PDF [170KB] 
  Form 1122

Mississippi State Department of Health • 570 East Woodrow Wilson Dr • Jackson, MS 39216 • 866‑HLTHY4U • Contact and information