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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, 2016.

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















WVA Tax ID: 27-2251833 | WVA NPI: 1699092718


Copyright 2013 Washington Vaccine Association