Contingency Plan For Vaccine Storage – Fill Out and Use This PDF

Facility Name: _____________________________________________

TVFC PIN: _______________

Address: _________________________________________________

Date: ___________________

City, State, Zip Code: _________________________________________

Phone: __________________

Clinic staff responsible for transfer of vaccine:

Phone number:

Name:

(

)

Name (back-up):

(

)

Transfer vaccine to:

Phone number:

Facility Name:

(

)

Address:

Generator: □ Yes □ No

Contact Name:

Date of agreement:

Where to obtain:

Phone number:

Ice:

(

)

Dry ice:

(

)

Cooler:

(

)

Shipping Agent:

Phone number:

Tracking number:

(

)

Contact with LHD/HSR made prior to transport by:

Transport of refrigerated vaccine checklist:

Temperature of refrigerator prior to transport:

Inventory of vaccine (use C-33) and included in bag with vaccine. Keep a copy for your records.

Bag labeled with PIN, clinic name, clinic contact, phone number.

Container used to transport refrigerated vaccine:

Ice packs are in container separated from vaccine by crumpled paper.

Thermometer in container.

Time and temperature in container prior to transport:

Person transporting vaccine:

Transport of frozen vaccine checklist:

Temperature of freezer prior to transport:

Inventory of vaccine (use C-33) and included in bag with vaccine. Keep a copy for your records.

Bag labeled with PIN, clinic name, clinic contact, phone number.

Container used to transport vaccine:

Varicella packed in dry ice.

Thermometer in container.

Time and temperature in container prior to transport:

Texas Department of State Health Services

Stock No. 11-11190

Immunization Branch

Rev. 07/2007