Form Dhec 1167 PDF Details

The DHEC 1167 form, integral to South Carolina's Vaccines for Children (VFC) program, serves as a critical tool for managing and documenting the borrowing of vaccines between VFC-enrolled providers' private and VFC vaccine stocks. It outlines a structured process for situations where vaccines need to be borrowed due to unexpected inventory shortages, such as delayed vaccine shipments or orders arriving non-viable. Its meticulous guidelines ensure that VFC vaccine borrowing does not hinder the ability of VFC-eligible children to receive their vaccinations. Providers are required to justify the borrowing through specified reasons and to certify the accuracy and compliance of their report under the threat of penalty under the False Claims Act among other laws. The form facilitates strict adherence to VFC program standards by mandating detailed documentation of each vaccine borrowed, including the vaccine type, patient details, the borrowing date, and the reason behind the stock shortage. Moreover, the form underscores the responsibility of the provider to replace borrowed vaccines to maintain a stable vaccine supply for both VFC-eligible and non-eligible children. The purposeful design of the DHEC 1167 underscores the balance between flexibility in vaccine management and the accountability of healthcare providers in upholding public health standards.

QuestionAnswer
Form NameForm Dhec 1167
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesD 1167 vfc vaccine borrowing report form in nyc

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SC VFC PROGRAM

VACCINE BORROWING REPORT

Contact Name

 

PIN #:

 

Provider

Street Address

City/State/Zip

PhoneFAX

VFC-enrolled providers are expected to maintain an adequate inventory of vaccine for both their VFC and non-VFC eligible patients. VFC vaccine cannot be used as a replacement system for a provider’s privately purchased vaccine inventory. Borrowing should occur only when there is lack of appropriate stock vaccine (VFC or provider-purchased) due to unexpected circumstances such as a delayed vaccine shipment, vaccine spoiled in-transit to provider, or new staff that calculated ordering time incorrectly. Routine/ planned/ sustained borrowing is not acceptable. The provider must assure that borrowing VFC vaccine will not prevent a VFC-eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible child.

 

 

 

 

 

 

 

 

Date Vaccine

Vaccine

Patient Name

DOB

Date Borrowed

 

Reason No Appropriate Stock Vaccine Was Available

Returned to

Borrowed

 

Appropriate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stock

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

1.

Private stock order delayed

2.

Private stock non-viable on arrival

 

 

 

 

 

3.

VFC order delayed

4.

VFC order non-viable on arrival

 

 

 

 

 

5.

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

“I hereby certify, subject to penalty under the False Claims Act (31 U.S.C. § 3730) and other applicable Federal and state law, that VFC vaccine dose borrowing and replacement reported on this form has been accurately reported and conducted in conformance with VFC provisions for such borrowing and further certify that all VFC doses borrowed during the noted time period have been fully reported on this form.”

Provider’s Printed Name:

 

Provider Signature:

 

Date:

 

 

 

 

 

 

 

DHEC 1167 (Rev. 3/2011)

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

 

 

 

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

SC VFC VACCINE BORROWING REPORT

Instructions for Completing

Purpose:

The purpose of the SC VFC Vaccine Borrowing Report is to provide documentation of borrowed vaccine from private stock or VFC stock.

Item-By-Item Instructions:

1.Enter Provider Identification Number and all contact information in space provided.

2.For each vaccine borrowed from either private stock or VFC stock, complete all fields (i.e., Vaccine Borrowed, Patient Name, Date of Birth, Date Borrowed and Reason No Appropriate Stock Was Available columns). Each vaccine a child receives must be listed on a separate row.

3.Once the vaccine is replaced, enter the date in the Date Vaccine Returned to Appropriate Stock column.

4.The provider must print, sign and date the form.

5.The provider must contact the SC VFC Program (803) 898-0460 upon each event.

Office Mechanics and Filing:

Completed SC VFC Vaccine Borrowing Report(s) are to be maintained by the provider as part of the VFC program records for (3) years. If copy is requested by the SC VFC Program, then it will also be retained for (3) years.

DHEC 1167 (Rev. 3/2011)

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL