Reporting Vaccine Services for Uninsured Service Members
Welcome to the Texas Department of State Health Services (DSHS) Immunization Unit online survey to report the number of uninsured service member that received Adult Safety Net (ASN) vaccines at your facility. The term service member includes both current and former members of either the state military forces or a component of the United States armed forces, including a reserve component.
In accordance with Section 434.214, Texas Government Code and Section 526.093, Texas Government Code, Texas DSHS must collect and report the number of uninsured female service members and total number of uninsured service members who receive ASN vaccines at your facility.
Tips for gathering data for the report:
- Every uninsured adult patient that receives a dose of ASN vaccine from your facility is required to fill out an adult eligibility screening form (F11-12842) (paper or electronic form). The newest version of this form (revised 08/2025) collects the gender of the patient along with their service member status.
- You and your staff can select the best way to manage these documents in your clinic.
- This report is due by the 7th of each month. Using the eligibility forms, you must enter the number of uninsured female service members and total service members who received ASN vaccine in your facility. Total service members include the number of female service members served.
- If there were no uninsured service members who received ASN vaccine in your facility for the previous month, you must report 0 for both questions.
Thank you for your continued participation in the ASN Program.
If you have any questions, please contact us via email at ASNInfo@dshs.texas.gov.