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. The 2019/20 WVA Assessment Grid goes into effect July 1, 2019. For Grids prior to current click Archived WVA Assessment Grids.
WVA W-9 Form (pdf)
The WVA W-9 required by the IRS.