Forms & Charts

Click on any of the forms or charts below to download them.

DBA Form Sample (pdf)
Completed samples of the two forms required for the dosage-based assessment (DBA) process.

Electronic Claim Sample (Excel) (pdf)
Spreadsheet that shows the fields and data for the electronic form format.

Washington Vaccine Association Assessment Grid
Chart listing the dosage-based assessment charges for vaccines covered by the state’s Childhood Vaccine Program.

WVA W-9 Form (pdf)
The WVA W-9 required by the IRS.