Vaccine Return Form by qiant230

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									                              Washington State Department of Health
                                       Immunization Program CHILD Profile
                                           Vaccine Return Addendum
Complete this form to document vaccine storage and handling incidents that result in spoiled (non-viable)
 vaccine that needs to be returned. Submit this form with the Vaccine Return Form for vaccine returns.
                       This form is required before a return is authorized by DOH
    Provider Name:                                                        Provider PIN:
    Date Submitted:                                                     Date of Incident:
        LHJ Name:
1. Was the spoiled vaccine known to have been exposed to more than one out-of-range storage
   temperature? Answer “Yes” if the decision to waste the vaccine was based upon a history of more than one improper
    storage incident involving the vaccine. If yes, answer subsequent questions based upon the most recent temperature.
        □ YES                                       □ NO                       □ DON’T KNOW
2. Was this event the result of vaccine being left outside the refrigerator/freezer storage unit?
     □ YES                                   □ NO                    □ DON’T KNOW
3. What type of refrigerator or freezer was involved?
      □ Refrigerator or □ Freezer in combination unit (“R/F”), separate thermostats for R and F
      □ Refrigerator or □ Freezer in R/F, single thermostat for both R and F
      □ Refrigerator or □ Freezer in R/F, unknown if single or separate thermostats
      Stand-alone □ refrigerator or □ freezer, household style
      Stand-alone □ refrigerator or □ freezer, commercial style
      Stand-alone □ refrigerator or □ freezer, “purpose-built” for storage of vaccines
      “Dormitory style” refrigerator □ or □ freezer (small, typically with interior freezer-box that has no
      external door). Note: If selected, LHJ must follow-up with provider to document the corrective action to
      replace the unit.
      □ Type of unit is unknown

4. For refrigerator storage vaccine:
   a. Was the temperature too warm or too cold?
           □ Too warm (above 8°C or 46°F)                             □ Too cold (below 2°C or 35°F)
            Use the most recent recorded out of range temperature if the decision to waste the vaccine was based upon a
            history of more than one improper storage incident involving the vaccine.

    b. How long was the vaccine outside the proper temperature range of 2°C/35°F through 8°C/46° F?
         □ In Hours: _______                             □ DON’T KNOW
            Report the actual time out of range in hours; if known, report the time from the most recently recorded in-range
            temperature until the discovery of the problem (in hours). (1 day = 24 hrs; 2 weeks=336 hrs; 60 days=1440 hrs)

5. For freezer storage vaccine:
   a. What was the maximum recorded temperature above 5 Fahrenheit (-15 Celsius)?
           □ ____°F
            Record temperature in degrees Fahrenheit up to one decimal point (e.g., “7.4”). Use the most recent recorded
            out of range temperature..

    b. How long was the vaccine above -15°C/+5°F?
         □ In hours: _______                                          □ DON’T KNOW
            Report the actual time out of range in hours; if known, report the time from the most recently recorded in-range
            temperature until the discovery of the problem (in hours). (1 day = 24 hrs; 2 weeks=336 hrs; 60 days=1440 hrs)
DOH Revised 07-2009                                                                                             Page 1 of 1

360-236-3597 FAX                      WA DOH Immunization Program CHILD Profile                   360-236-3595 Main Phone
                       Public Health – Always Working for a Safer and Healthier Washington

								
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