Vfc Vaccine Transfer Form – Fill Out and Use This PDF

Massachusetts Department of Public Health

Division of Epidemiology and Immunization

VFC Vaccine Transfer Form

Guidance: Vaccine loss due to expiration is frequently a consequence of over ordering, poor inventory management or low volume usage. VFC-enrolled providers are expected to check their current vaccine inventory expiration dates monthly. If short dated vaccine (vaccine due to expire in 2 months) is found, the vaccine may be transferred to another provider so that it may be used prior to expiration. MDPH instituted a Vaccine Restitution Policy effective January 1, 2011 which requires providers to make restitution for any federal or state purchased vaccines that have been lost due to provider’s failure to properly receive, store or handle vaccine inventory. This includes failure to rotate vaccine stock, resulting in expired vaccine.

It is the provider’s responsibility to locate another pediatric practice and transfer short dated vaccine. If the provider is unable to locate a pediatric practice in their area, call the Vaccine Unit for assistance. (617-983-6828)

Directions for use of this form: Refrigerated vaccine must be transported in a cooler with cold packs, not freezer packs. Providers must fill out the VFC Vaccine Transfer Form and fax to the Vaccine Unit @ 617-983-6924. Both providers should keep a signed copy of the completed form in their office records.

Fax the completed form to: 617-983-6924 ATTN: MDPH Vaccine Unit

Transferred from-Provider Name: __________________________________________________Provider Site Number: ___________

Office Contact Name: ______________________________

Tel: _________________________

Transferred to-Provider Name: _____________________________________________________Provider Site Number:____________

Office Contact Name:_______________________________

Tel:__________________________

Transferred

Number

Lot # and

Date

Reason for short dated

Transferred

Number of

Lot # and

Date

Reason for short dated vaccine

Vaccine

of Doses

Expiration

Transferred

vaccine (circle one)

Vaccine

Doses

Expiration

Transferred

(circle one)

Date

Date

1.Low volume use

1.Low volume use

2.

Over ordering

2.

Over ordering

3.

Not rotating stock

3.

Not rotating stock

4.

Other (specify)

4.

Other (specify)

1.Low volume use

1.Low volume use

2.

Over ordering

2.

Over ordering

3.

Not rotating stock

3.

Not rotating stock

4.

Other (specify)

4.

Other (specify)

1.Low volume use

1.Low volume use

2.

Over ordering

2.

Over ordering

3.

Not rotating stock

3.

Not rotating stock

4.

Other (specify)

4.

Other (specify)

1.Low volume use

1.Low volume use

2.

Over ordering

2.

Over ordering

3.

Not rotating stock

3.

Not rotating stock

4.

Other (specify)

4.

Other (specify)

Recipient Provider Signature: ___________________________________

Date: ____________

Vaccine-Management-transfer-form.doc

March 2013