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. Updated WVA Assessment Grid goes into effect July 1, 2017. For Grids prior to current click Archived WVA Assessment Grids.
WVA W-9 Form (pdf)
The WVA W-9 required by the IRS.