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Vaccine Direct Return Form

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					Washington State Department of Health
Immunization Program CHILD Profile Vaccine Return Form
For providers returning expired/spoiled state supplied vaccine(s) directly to McKesson*
Date: Provider PIN: Returned By: Provider Name: Telephone: Provider Address: City: State: Zip: LHJ Name: Date LHJ was Contact: Return Instructions: 1. To cause the least interference with vaccine order processing, please fax vaccine return forms and return the vaccine after the 15th of the month. 2. A vaccine return form must be completed for each provider returning spoiled or expired vaccine(s), and the PIN number must be included. 3. Fax a copy of this form to the Washington State Department of Health 2 days prior to returning the vaccine. Washington State Department of Health Fax # (360) 236-3597 4. Include a copy of this form with returned shipment and send a copy to your local health jurisdiction. 5. Use a shipping carton received from McKesson and the UPS return label provided with the carton. Returns should be given to the UPS delivery person at the next UPS pick-up or drop off to avoid pick-up charges. If you do not have a shipping carton or return label, contact your local health jurisdiction for options.

Vaccine**

Number of Doses Returned

Manufacturer

Lot Number

Expiration Date

Return Reason Code (see below)

DT DTaP DTaP-Hep B-IPV DTaP-IPV-Hib Hep A Hep B Hib HPV IPV MCV4 MMR MMR-V PCV7 PPV23 Rotavirus Td Tdap Varicella Use the next page for additional lot number. Please print or type legibly. Return Reason Codes: 1. Expired 2. Refrigerator / Freezer failure – too warm Explain: 3. Refrigerator / Freezer failure – too cold 4. Failure to store properly on receipt 5. Natural Disaster 6. Spoiled - other

Corrective Action:

Address for vaccine returns sent directly to McKesson Specialty (Please follow LHJ instructions for returning vaccines)

McKesson Specialty 3775 Seaport Blvd West Sacramento, CA 95691 Attn: Vaccine Returns
* For returning vaccine(s) directly to your local health jurisdiction, please see the return form supplied by your LHJ. ** Influenza vaccine returns will be processed using a separate form.

360-236-3597 FAX
DOH Revised 06-2009

WA DOH Immunization Program CHILD Profile

360-236-3595 Main Phone

Public Health – Always Working for a Safer and Healthier Washington

Washington State Department of Health
Immunization Program CHILD Profile Vaccine Return Form (cont.)
For providers returning expired/spoiled state supplied vaccine(s) directly to McKesson*

Additional vaccine lot numbers returned
Date: Provider PIN:

Vaccine**
DT DTaP DTaP-Hep B-IPV DTaP-IPV-Hib Hep A Hep B Hib HPV IPV MCV4 MMR MMR-V PCV7 PPV23 Rotavirus Td Tdap Varicella

Number of Doses Returned

Manufacturer

Lot Number

Expiration Date

Return Reason Code (see below)

Return Reason Codes: 1. Expired 2. Refrigerator / Freezer failure – too warm

3. Refrigerator / Freezer Failure – too cold 4. Failure to store properly on receipt

5. Natural Disaster 6. Spoiled - other

Address for vaccine returns sent directly to McKesson Specialty (Please follow LHJ instructions for returning vaccines)

McKesson Specialty 3775 Seaport Blvd West Sacramento, CA 95691 Attn: Vaccine Returns
* For returning vaccine(s) directly to your local health jurisdiction, please see the return form supplied by your LHJ. ** Influenza vaccine returns will be processed using a separate form.

360-236-3597 FAX
DOH Revised 06-2009

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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