EC-33MonthlyBioRpt102110

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					                                                                                                                Texas Vaccines for Children
                                                                                                                 Monthly Biological Report
                                                                                                                                                                                         TVFC PIN:* _____________________


        Contact Person*
                                                                                                                                                                                            Month*          Year*
        (      )                                       (      )
        Phone*                                         Fax*                                Clinic Name and Address:*




        Use additional forms for additional lot #s                                 A            B           C           D            E          F             G               H                 I             J               K
                                                                                Doses on     Doses                       Doses                TOTAL         Doses          Doses           Doses on       Physical      Doses
                                                                                 Hand       Received    SUBTOTAL       Administered           DOSES                                                        Count       Lost - or
                                                                  Expiration                                                                                             Ruined, or      Hand at END
                    Vaccine Type                     Lot Number                             DURING                                                        Transferred
                                                                    Date       BEGINNING                                      AGE          ADMINISTERED                   Expired         OF MONTH         END OF      Gained +
                                                                                              THE        A+B=C
                                                                               OF MONTH                                                                                                                    MONTH
                                                                                            MONTH                      <=18         >=19      D+E=F         EC-67       EC-69 Required      C-F-G-H=I                  J-I=K+/-
                          DT

        DT, single-dose vial (Ped)


        GRAND TOTAL Number of Doses
                   DTaP
        DAPTACEL, single-dose vial
        (Ped)
        INFANRIX, single-dose vial
        (Ped)

        INFANRIX, PF Syringe (Ped)

        TRIPEDIA, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses
             DTaP/HepB/IPV
        PEDIARIX, PF syringe (Ped)


        GRAND TOTAL Number of Doses
               DTaP/IPV

        KINRIX, single-dose vial (Ped)

        KINRIX, PF syringe (Ped)


        GRAND TOTAL Number of Doses
              DTaP/IPV/Hib
        PENTACEL, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses
                Hep A

        HAVRIX, single-dose vial (Ped)

        HAVRIX, PF syringe (Ped)

        VAQTA, single-dose vial (Ped)


        GRAND TOTAL Number of Doses

Form EC-33                                                                                                                                                                                                                  Rev. 10/21/2010
                                                                                                             Texas Vaccines for Children
                                                                                                              Monthly Biological Report                                             TVFC PIN:* _____________________
                                                                                                                       page 2

                                                                                                                                                                                       Month*          Year*
        Use additional forms for additional lot #s                                 A          B          C         D            E          F             G               H                 I             J               K
                                                                                Doses on    Doses                   Doses                TOTAL         Doses          Doses           Doses on       Physical      Doses
                                                                                 Hand      Received   SUBTOTAL    Administered           DOSES                                                        Count       Lost - or
                                                                  Expiration                                                                                        Ruined, or      Hand at END
                    Vaccine Type                     Lot Number                            DURING                                                    Transferred
                                                                    Date       BEGINNING                                 AGE          ADMINISTERED                   Expired         OF MONTH         END OF      Gained +
                                                                                             THE       A+B=C
                                                                               OF MONTH                                                                                                               MONTH
                                                                                           MONTH                  <=18         >=19      D+E=F         EC-67       EC-69 Required      C-F-G-H=I                  J-I=K+/-
                  Hep B
        ENGERIX B, single-dose vial
        (Ped)

        ENGERIX B, PF syringe (Ped)

        RECOMBIVAX HB, single-dose
        vial (Ped)

        GRAND TOTAL Number of Doses
              Hep A / Hep B
        TWINRIX, single-dose vial
        (Ped)

        TWINRIX, PF syringe (Ped)


        GRAND TOTAL Number of Doses
               Hep B-HIB
        COMVAX, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses
                 HIB

        ACTHIB, single-dose vial (Ped)

        HIBERIX, single-dose vial
        (Ped)
        PEDVAXHIB, single-dose vial
        (Ped)


        GRAND TOTAL Number of Doses
                   HPV
        CERVARIX, single-dose vial
        (Ped)

        CERVARIX, PF syringe (Ped)

        GARDASIL, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses
                 IPV
        IPOL, multi-dose vial (Ped)


        GRAND TOTAL Number of Doses



Form EC-33                                                                                                                                                                                                             Rev. 10/21/2010
                                                                                                             Texas Vaccines for Children                                       TVFC PIN:* _____________________
                                                                                                              Monthly Biological Report
                                                                                                                       page 3
                                                                                                                                                                                  Month*          Year*
        Use additional forms for additional lot #s                                 A          B          C         D            E        F             G              H               I             J               K
                                                                                Doses on    Doses                    Doses             TOTAL         Doses          Doses         Doses on      Physical       Doses
                                                                  Expiration     Hand      Received
                                                                                           DURING     SUBTOTAL    Administered         DOSES                      Ruined, or    Hand at END      Count       Lost - or
                    Vaccine Type                     Lot Number                                                                                    Transferred
                                                                    Date       BEGINNING    THE                        AGE          ADMINISTERED                   Expired       OF MONTH       END OF       Gained +
                                                                                                       A+B=C
                                                                               OF MONTH    MONTH                  <=18     >=19        D+E=F         EC-67       EC-69 Required   C-F-G-H=I     MONTH         J-I=K+/-
                  MCV4
        MENACTRA, single-dose vial
        (Ped)
        MENVEO, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses
                 MMR
        MMR II, single-dose vial (Ped)

        GRAND TOTAL Number of Doses
                 MMRV
        PROQUAD, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses
                 PCV7
        PREVNAR, PF syringe (Ped)


        GRAND TOTAL Number of Doses
                 PCV13
        PREVNAR 13, PF syringe
        (Ped)

        GRAND TOTAL Number of Doses
                   PPSV23
        PNEUMOVAX 23, single-dose
        vial (Ped)

        GRAND TOTAL Number of Doses
               Rotavirus
        ROTARIX, oral applicator (Ped)

        ROTATEQ, oral applicator
        (Ped)

        GRAND TOTAL Number of Doses
                    Td
        DECAVAC, single-dose vial
        (Ped)

        DECAVAC, PF syringe (Ped)

        Td-MassbioLogics, single-dose
        vial (Ped)

        GRAND TOTAL Number of Doses




Form EC-33                                                                                                                                                                                                        Rev. 10/21/2010
                                                                                                                                               Texas Vaccines for Children                                           TVFC PIN:* _____________________
                                                                                                                                                Monthly Biological Report
                                                                                                                                                         page 4
                                                                                                                                                                                                                        Month*          Year*
        Use additional forms for additional lot #s                                                          A               B              C         D            E           F            G              H                 I             J               K
                                                                                                       Doses on         Doses                         Doses              TOTAL           Doses          Doses          Doses on       Physical      Doses
                                                                                     Expiration         Hand           Received
                                                                                                                       DURING        SUBTOTAL       Administered         DOSES                        Ruined, or     Hand at END       Count       Lost - or
                       Vaccine Type                               Lot Number                                                                                                          Transferred
                                                                                       Date           BEGINNING          THE                           AGE            ADMINISTERED                     Expired        OF MONTH        END OF       Gained +
                                                                                                                                       A+B=C
                                                                                                      OF MONTH         MONTH                        <=18      >=19       D+E=F           EC-67      EC-69 Required      C-F-G-H=I     MONTH        J-I=K+/-
                   TDAP
        ADACEL, single-dose vial
        (Ped)

        ADACEL, PF syringe (Ped)

        BOOSTRIX, single-dose vial
        (Ped)

        BOOSTRIX, PF syringe (Ped)


        GRAND TOTAL Number of Doses
               VARICELLA
        VARIVAX, single-dose vial
        (Ped)

        GRAND TOTAL Number of Doses




                                                                                                                                                            Comment Section: Must explain lost or gained doses from column K

        * Required Field

        This certifies that this report is a true accounting of the above biologicals received from the Texas Department of State Health
        Services that were administered during the reported time period. No one was refused immunizations for failure to pay an
        administrative fee or make a donation to the provider.




        Approved by: (Physician or other authorized signature)*                                                                     Date


        DSHS/LHD USE ONLY
        Processed By:                                                                                                                                                 Date:




Form EC-33                                                                                                                                                                                                                                              Rev. 10/21/2010
                                                                                                              Texas Vaccines for Children
                                                                                                       Adult Safety Net Monthly Biological Report
                                                                                                                                                                                    TVFC PIN:* _____________________



        Contact Person*
                                                                                                                                                                                       Month*          Year*
        (      )                                       (      )
        Phone*                                         Fax*                                Clinic Name and Address:*




        Use additional forms for additional lot #s                                 A            B           C           D        E         F             G               H                 I             J               K
                                                                                Doses on     Doses                       Doses           TOTAL         Doses          Doses           Doses on       Physical      Doses
                                                                  Expiration     Hand       Received
                                                                                            DURING       SUBTOTAL      Administered      DOSES                      Ruined, or      Hand at END       Count       Lost - or
                    Vaccine Type                     Lot Number                                                                                      Transferred
                                                                    Date       BEGINNING      THE                         AGE         ADMINISTERED                   Expired         OF MONTH        END OF       Gained +
                                                                                                          A+B=C
                                                                               OF MONTH      MONTH                     <=18    >=19      D+E=F         EC-67       EC-69 Required      C-F-G-H=I     MONTH        J-I=K+/-
                   HEP A
        HAVRIX, single-dose vial
        (Adult)

        HAVRIX, PF syringe (Adult)


        GRAND TOTAL Number of Doses
                 HEB B
        ENGERIX-B, single-dose vial
        (Adult)

        ENGERIX-B, PF syringe (Adult)


        GRAND TOTAL Number of Doses
                HEP A/HEP B
        TWINRIX, single-dose vial
        (Adult)

        TWINRIX, PF syringe (Adult)


        GRAND TOTAL Number of Doses
                   HPV
        CERVARIX, single-dose vial
        (Adult)

        CERVARIX, PF syringe (Adult)

        GARDASIL, single-dose vial
        (Adult)

        GRAND TOTAL Number of Doses
                 MCV4
        MENACTRA, single-dose vial
        (Adult)

        GRAND TOTAL Number of Doses
                 MMR
        MMR II, single-dose vial (Adult)

        GRAND TOTAL Number of Doses


Form EC-33                                                                                                                                                                                                             Rev. 10/21/2010
                                                                                                                                         Texas Vaccines for Children
                                                                                                                                  Adult Safety Net Monthly Biological Report                                     TVFC PIN:* _____________________
                                                                                                                                                     page 2

                                                                                                                                                                                                                    Month*          Year*
        Use additional forms for additional lot #s                                                          A               B              C     D            E           F            G              H                 I             J               K
                                                                                                       Doses on         Doses                     Doses              TOTAL           Doses          Doses          Doses on       Physical      Doses
                                                                                     Expiration         Hand           Received
                                                                                                                       DURING        SUBTOTAL   Administered         DOSES                        Ruined, or     Hand at END       Count       Lost - or
                       Vaccine Type                               Lot Number                                                                                                      Transferred
                                                                                       Date           BEGINNING          THE                       AGE            ADMINISTERED                     Expired        OF MONTH        END OF       Gained +
                                                                                                                                       A+B=C
                                                                                                      OF MONTH          MONTH                   <=18      >=19       D+E=F           EC-67      EC-69 Required      C-F-G-H=I     MONTH        J-I=K+/-
                     PPSV23
        PNEUMOVAX 23, single-dose
        vial (Adult)
        PNEUMOVAX 23, Multi-dose
        vial (Adult)

        GRAND TOTAL Number of Doses
                  Td
        DECAVAC, PF syringe (Adult)

        Akorn, single-dose vial (Adult)

        MassBioLogics, single-dose
        vial (Adult)

        GRAND TOTAL Number of Doses
                   TDAP
        ADACEL, single-dose vial
        (Adult)

        ADACEL, PF syringe (Adult)

        BOOSTRIX, single-dose vial
        (Adult)
        BOOSTRIX, PF syringe (Adult)

        GRAND TOTAL Number of Doses
                VARICELLA
        VARIVAX, single-dose vial
        (Adult)

        GRAND TOTAL Number of Doses
                ZOSTER
        ZOSTAVAX, single-dose vial
        (Adult)

        GRAND TOTAL Number of Doses
                                                                                                                                                        Comment Section: Must explain lost or gained doses from column K
        * Required Field

        This certifies that this report is a true accounting of the above biologicals received from the Texas Department of State Health
        Services that were administered during the reported time period. No one was refused immunizations for failure to pay an
        administrative fee or make a donation to the provider.



        Approved by: (Physician or other authorized signature)*                                                                     Date

        DSHS/LHD USE ONLY
        Processed By:                                                                                                                                             Date:




Form EC-33                                                                                                                                                                                                                                          Rev. 10/21/2010
                                                                                                                                            Texas Vaccines for Children
                                                                                                                                       Influenza Monthly Biological Report
                                                                                                                                                                                                                 TVFC PIN:* _____________________


        Contact Person*
                                                                                                                                                                                                                    Month*          Year*
        (      )                                                    (      )
        Phone*                                                      Fax*                                             Clinic Name and Address:*




        Use additional forms for additional lot #s                                                          A               B              C      D        E             F             G              H                 I             J               K
                                                                                                       Doses on         Doses                      Doses            TOTAL            Doses          Doses          Doses on       Physical      Doses
                                                                                     Expiration         Hand           Received
                                                                                                                       DURING        SUBTOTAL    Administered       DOSES                         Ruined, or     Hand at END       Count       Lost - or
                       Vaccine Type                               Lot Number                                                                                                      Transferred
                                                                                       Date           BEGINNING          THE                        AGE          ADMINISTERED                      Expired        OF MONTH        END OF       Gained +
                                                                                                                                       A+B=C
                                                                                                      OF MONTH         MONTH                     <=18    >=19       D+E=F            EC-67      EC-69 Required      C-F-G-H=I     MONTH        J-I=K+/-
                        Influenza
        Fluzone, 0.25 mL PF Syringe

        Fluzone, 0.5 mL single-dose
        vial

        Fluzone, 0.5 mL PF Syringe

        Fluzone, 10 Dose Vial

        Flurarix, 0.5mL PF Syringe

        Flumist, Intranasal

        Fluvirin, 0.5mL PF Syringe

        Fluvirin, 10 Dose Vial

        Afluriam, 0.5mL PF Syringe


        GRAND TOTAL Number of Doses
                                                                                                                                                        Comment Section: Must explain lost or gained doses from column K
        * Required Field

        This certifies that this report is a true accounting of the above biologicals received from the Texas Department of State Health
        Services that were administered during the reported time period. No one was refused immunizations for failure to pay an
        administrative fee or make a donation to the provider.



        Approved by: (Physician or other authorized signature)*                                                                     Date

        DSHS/LHD USE ONLY
        Processed By:                                                                                                                                            Date:




Form EC-33                                                                                                                                                                                                                                          Rev. 10/21/2010
Form EC-33   Rev. 10/21/2010
Form EC-33   Rev. 10/21/2010
Form EC-33   Rev. 10/21/2010

				
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