NASHVILLE (AP) — As controversy raged on over the firing of Tennessee's vaccination leader after state lawmakers complained about efforts to promote COVID-19 vaccination among teenagers, state officials released documents Thursday that for the first time offer other reasons for her dismissal.

Tennessee's chief medical officer reasoned that the state's now-fired vaccination leader should be removed partly due to complaints about her leadership approach and how she handled a letter about vaccination rights of minors that incensed some Republican lawmakers, state records show.

In a letter dated July 9 and obtained through a public records request, Chief Medical Officer Dr. Tim Jones wrote that Dr. Michelle Fiscus deserved to be fired because of "failure to maintain good working relationships with members of her team, her lack of effective leadership, her lack of appropriate management, and unwillingness to consult with superiors and other internal stakeholders on (Vaccine Preventable Diseases and Immunization Program) projects."

In rebuttal, Fiscus's husband Brad circulated three of the last four years' worth of performance reviews deeming her work "outstanding," most recently for October 2019 through September 2020. They are seeking the 2018-19 review — also positive — from the department, Brad Fiscus said. He said they didn't know about the July 9 letter until Thursday and questioned why it wasn't used at her July 12 firing.

"Dr. Fiscus has been attentive to her team," the 2019-2020 review says. "She has exceed(ed) expectations in managing all programmatic activities while being fully immersed in (COVID-19) response efforts. She has appropriately and effectively advocated for her team. Her program has had some key transitions during this evaluation period which have been managed well."

Fiscus continues to speak widely after her firing Monday, which she has said was a political move to appease lawmakers who disapproved of the Department of Health's outreach to get teens vaccinated for COVID-19. Additionally, the department acknowledged in email records that it has halted all outreach efforts around any kind of vaccines for children, not just COVID-19 ones, as The Tennessean first confirmed.

In a statement Thursday, Health Commissioner Lisa Piercey said there has been "no disruption to the childhood immunization program or access to the COVID-19 vaccine while the department has evaluated annual marketing efforts intended for parents." The department pointed parents seeking information on childhood vaccines to state websites.

"We are proud of the efforts of our staff across the state and will continue to promote vaccination and the vaccination work of our partners," Piercey said.

Tennessee ranks in the bottom 10 of vaccination rates among states, at 38%. COVID-19 cases have begun rising again, with Tennessee's rolling average of daily new cases up by 451.4 over two weeks, an increase of 680.5%, according to Johns Hopkins University researchers.

The day of her firing, Fiscus penned a blistering 1,200-word response saying she is ashamed of Tennessee's leaders, afraid for her state, and "angry for the amazing people of the Tennessee Department of Health who have been mistreated by an uneducated public and leaders who have only their own interests in mind."

Her termination letter did not specify why she was fired.

The letter recommending her firing, sent to Piercey, cites several reasons. The dates of issues claimed fell after her last performance review period.

It says staffers complained about "her management style, treatment of employees, and poor program morale"; she had to take coaching sessions, including on "professionalism and teamwork" after a disagreement with another departmental physician; "repetitive, long, and inefficient meetings" because she did not delegate work enough; she requested to use department funding for a nonprofit she founded and led; and that she communicated directly, without notifying supervisors, to produce COVID-19 vaccine reports for a state university.

The recommendation came after a June committee meeting, when angry Republican lawmakers named Fiscus over a letter she sent medical providers who administer vaccines explaining the state's legal mechanism letting them vaccinate minors as young as 14 without parental consent, called the "Mature Minor Doctrine." The letter was in response to providers' questions and didn't contain new information.

Fiscus said the health department's attorney provided language for the letter, based on a 1987 Tennessee Supreme Court ruling. Fiscus said she was doing her job to explain what is allowable.

The recommendation to fire Fiscus calls the memo "her own interpretation of state and federal law" and says she didn't involve the department legal counsel or leadership in drafting it, disputing her account.

The letter says the memo created "confusion of both law and policy for private providers, parents, and legislators."

Republican lawmakers also admonished the agency for its communications about the vaccine, including online posts. One graphic, featuring a photo of a smiling child with a Band-Aid on his arm, said, "Tennesseans 12+ are eligible for vaccines. Give COVID-19 vaccines a shot." Some lawmakers even threatened to dissolve the Health Department.

A few days before she was fired, Fiscus received a dog muzzle via mail at work, which Brad Fiscus reasoned that "someone wanted to send a message to tell her to stop talking."

The Tennessee Department of Safety and Homeland Security said it is investigating the incident.

Meanwhile, in the state's most populous county, the Shelby County Health Department is continuing regular vaccination outreach programs. The department is publicizing a Memphis event Saturday with back-to-school vaccinations, including COVID-19 shots for children 12 and older and their parents.

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Adrian Sainz in Memphis and Travis Loller in Nashville contributed to this report.