Are you looking for information about Form Dhec 1167? It can be hard to find reliable source material on this form. That's why we've put together this guide, providing an overview of the purpose and function of Form Dhec 1167. With our help, you can learn how to properly fill out and submit this important document, as well as understand when it is needed in order to stay compliant with regulatory requirements. Let's take a closer look at Form Dhec 1167 — what it is, why it’s important, and how it should be filed in your state of operations.
| Question | Answer |
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| Form Name | Form Dhec 1167 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | D 1167 vfc vaccine borrowing report form in nyc |
SC VFC PROGRAM
VACCINE BORROWING REPORT
Contact Name |
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PIN #: |
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Provider
Street Address
City/State/Zip
PhoneFAX
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Date Vaccine |
Vaccine |
Patient Name |
DOB |
Date Borrowed |
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Reason No Appropriate Stock Vaccine Was Available |
Returned to |
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Borrowed |
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Appropriate |
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Stock |
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1. |
Private stock order delayed |
2. |
Private stock |
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VFC order delayed |
4. |
VFC order |
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Other (specify) |
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1. |
Private stock order delayed |
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Private stock |
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VFC order delayed |
4. |
VFC order |
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Other (specify) |
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1. |
Private stock order delayed |
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Private stock |
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3. |
VFC order delayed |
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VFC order |
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5. |
Other (specify) |
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1. |
Private stock order delayed |
2. |
Private stock |
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3. |
VFC order delayed |
4. |
VFC order |
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5. |
Other (specify) |
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1. |
Private stock order delayed |
2. |
Private stock |
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3. |
VFC order delayed |
4. |
VFC order |
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5. |
Other (specify) |
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1. |
Private stock order delayed |
2. |
Private stock |
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3. |
VFC order delayed |
4. |
VFC order |
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5. |
Other (specify) |
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1. |
Private stock order delayed |
2. |
Private stock |
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3. |
VFC order delayed |
4. |
VFC order |
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Other (specify) |
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“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: |
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Provider Signature: |
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Date: |
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DHEC 1167 (Rev. 3/2011) |
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL |
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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.
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)
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 |