DOH Form 348-077 "Refrigerator Temperature Monitoring Log" - Washington

What Is Form DOH348-077?

This is a legal form that was released by the Washington State Department of Health - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Washington State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOH348-077 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download DOH Form 348-077 "Refrigerator Temperature Monitoring Log" - Washington

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REFRIGERATOR TEMPERATURE MONITORING LOG: Days 1-15
F° C°
CLINIC NAME:______________________________
PROVIDER PIN:_______________________
FRIDGE NAME/NUMBER:_____________________ MONTH & YEAR:______________________
0.
INSTRUCTIONS ON HOW TO RECORD TEMPERATURES:
0.
Take action if temp is out of range - too warm (above 46°F / 8°C) or too cold (below 36°F / 2°C):
1.
Enter Provider Information and circle if you are recording in C° or F° on the temperature log.
1.
Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
2.
Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health
3.
Record min/max once each workday (since previous recording), preferably in the morning.
2a.
department.
4.
2.
Record current temps twice, at beginning and end of each workday.
Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
5.
3.
Put an “X” in the row that corresponds to the refrigerator’s temperature.
Notify your vaccine coordinator and follow the Vaccine Temperature Excursion Guide.
6.
4.
If any out-of-range temp, see instructions to the right.
Notify the state of the excursion, viability of the vaccines, and actions taken.
7.
After each month has ended, save each month’s log for 3 years.
For more information, visit: www.doh.wa.gov/CVP > Storage and Handling
Day of Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Min/Max Temp
Refrigerator
am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm
Exact Time of
Temp
Room Temp
Staff Initials
49°F (9.5°C)
48°F (8.9°C)
47°F (8.4°C)
46°F (8°C)
45°F (7.3°C)
44°F (6.8°C)
43°F (6.2°C)
42°F (5.5°C)
41°F (5.0°C)
AIM for
40°F (4.5°C)
39°F (3.9°C)
38°F (3.4°C)
37°F (2.7°C)
36°F (2°C)
35°F (1.7°C)
34°F (1.1°C)
33°F (0.6°C)
≤32°F (0.0°C)
DATE
°F /°C
Action Taken: Fridge control adjusted, notified DOH
1/1
33.1 °F
etc.
Please list any steps
you've taken to address
temperature or storage
unit issues
If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-077 June 2020
REFRIGERATOR TEMPERATURE MONITORING LOG: Days 1-15
F° C°
CLINIC NAME:______________________________
PROVIDER PIN:_______________________
FRIDGE NAME/NUMBER:_____________________ MONTH & YEAR:______________________
0.
INSTRUCTIONS ON HOW TO RECORD TEMPERATURES:
0.
Take action if temp is out of range - too warm (above 46°F / 8°C) or too cold (below 36°F / 2°C):
1.
Enter Provider Information and circle if you are recording in C° or F° on the temperature log.
1.
Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
2.
Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health
3.
Record min/max once each workday (since previous recording), preferably in the morning.
2a.
department.
4.
2.
Record current temps twice, at beginning and end of each workday.
Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
5.
3.
Put an “X” in the row that corresponds to the refrigerator’s temperature.
Notify your vaccine coordinator and follow the Vaccine Temperature Excursion Guide.
6.
4.
If any out-of-range temp, see instructions to the right.
Notify the state of the excursion, viability of the vaccines, and actions taken.
7.
After each month has ended, save each month’s log for 3 years.
For more information, visit: www.doh.wa.gov/CVP > Storage and Handling
Day of Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Min/Max Temp
Refrigerator
am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm
Exact Time of
Temp
Room Temp
Staff Initials
49°F (9.5°C)
48°F (8.9°C)
47°F (8.4°C)
46°F (8°C)
45°F (7.3°C)
44°F (6.8°C)
43°F (6.2°C)
42°F (5.5°C)
41°F (5.0°C)
AIM for
40°F (4.5°C)
39°F (3.9°C)
38°F (3.4°C)
37°F (2.7°C)
36°F (2°C)
35°F (1.7°C)
34°F (1.1°C)
33°F (0.6°C)
≤32°F (0.0°C)
DATE
°F /°C
Action Taken: Fridge control adjusted, notified DOH
1/1
33.1 °F
etc.
Please list any steps
you've taken to address
temperature or storage
unit issues
If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-077 June 2020
REFRIGERATOR TEMPERATURE MONITORING LOG: Days 16-31
F° C°
CLINIC NAME:____________________________
PROVIDER PIN:_____________________
FRIDGE NAME/NUMBER:___________________
MONTH & YEAR:____________________
0.
INSTRUCTIONS ON HOW TO RECORD TEMPERATURES:
0.
Take action if temp is out of range - too warm (above 46°F / 8°C) or too cold (below 36°F / 2°C):
1.
Circle if you are recording in C° or F° on the temperature log.
1.
Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible. Do
2.
2a.
Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
not discard vaccines unless directed to by the manufacturer(s) and/or your state health
3.
Record min/max once each workday (since previous recording), preferably in the morning.
2.
department.
4.
3.
Record current temps twice, at beginning and end of each workday.
Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
5.
Put an “X” in the row that corresponds to the refrigerator’s temperature.
4.
Notify your vaccine coordinator and follow the Vaccine Temperature Excursion Guide.
6.
If any out-of-range temp, see instructions to the right.
Notify the state of the excursion, viability of the vaccines, and actions taken.
7.
After each month has ended, save each month’s log for 3 years.
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day of Month
Min/Max Temp
Refrigerator
am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm
Exact Time of
Temp
Room Temp
Staff Initials
49°F (9.5°C)
48°F (8.9°C)
47°F (8.4°C)
46°F (8°C)
45°F (7.3°C)
44°F (6.8°C)
43°F (6.2°C)
42°F (5.5°C)
41°F (5.0°C)
AIM for
40°F (4.5°C)
39°F (3.9°C)
38°F (3.4°C)
37°F (2.7°C)
36°F (2°C)
35°F (1.7°C)
34°F (1.1°C)
33°F (0.6°C)
≤32°F (0.0°C)
DATE
°F /°C
Action Taken: Fridge control adjusted, notified
Please list any steps
you've taken to address
1/1
33.1 °F
DOH etc.
temperature or storage
unit issues
If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-077 June 2020
FREEZER TEMPERATURE MONITORING LOG: Days 1-15
CLINIC NAME:______________________________ PROVIDER PIN:_______________________
FREEZER NAME/NUMBER:___________________
MONTH & YEAR:______________________
0.
INSTRUCTIONS ON HOW TO RECORD TEMPERATURES:
0.
Take action if temp is out of range - too warm (above 6°F / -14.4°C) or too cold (below -57°F / -
1.
Circle if you are recording in C° or F° on the temperature log.
1.
50°C):
2.
Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
2a.
Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
3.
Record min/max once each workday (since previous recording), preferably in the morning.
2.
Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health
4.
3.
Record current temps twice, at beginning and end of each workday.
department.
5.
4.
Put an “X” in the row that corresponds to the freezer’s temperature.
Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
6.
If any out-of-range temp, see instructions to the right.
Notify your vaccine coordinator and follow the Vaccine Temperature Excursion Guide.
7.
After each month has ended, save each month’s log for 3 years.
Notify the state of the excursion, viability of the vaccines, and actions taken.
Day of Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Min/Max Temp
Freezer
am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm
Exact Time of
Temp
Room Temp
Staff Initials
8°F (-13.4°C)
7°F (-13.9°C)
6°F (-14.4°C)
5°F (-15.0°C)
4°F (-15.6°C)
3°F (-16.1°C)
2°F (-16.7°C)
1°F (-17.2°C)
0°F (-17.8°C)
-1°F (-18.3°C)
-2°F (-18.9°C)
-3°F (-19.4°C)
-4°F (-20.0°C)
-5°F (-20.6°C)
-6°F (-21.1°C)
-7°F to -57°F
≤-58°F (-50°C)
DATE
°F /°C
Action Taken: Fridge control adjusted, notified DOH
Please list any steps
you've taken to address
1/1
33.1 °F
etc.
temperature or storage
unit issues
If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-077 June 2020
FREEZER TEMPERATURE MONITORING LOG: Days 16-31
F° C°
CLINIC NAME:____________________________
PROVIDER PIN:_____________________
FREEZER NAME/NUMBER:__________________
MONTH & YEAR:____________________
0.
INSTRUCTIONS ON HOW TO RECORD TEMPERATURES:
0.
Take action if temp is out of range - too warm (above 6°F / -14.4°C) or too cold (below -57°F /
1.
Circle if you are recording in C° or F° on the temperature log.
-50°C):
2.
1.
Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
3.
Record min/max once each workday (since previous recording), preferably in the morning.
Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health
4.
Record current temps twice, at beginning and end of each workday.
2a.
department.
5.
2.
Put an “X” in the row that corresponds to the freezer’s temperature.
Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
6.
If any out-of-range temp, see instructions to the right.
3.
Notify your vaccine coordinator and follow the Vaccine Temperature Excursion Guide.
7.
After each month has ended, save each month’s log for 3 years.
4.
Notify the state of the excursion, viability of the vaccines, and actions taken.
For more information, visit: www.doh.wa.gov/CVP > Storage and Handling
Day of Month
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Min/Max Temp
Freezer
am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm
Exact Time of
Temp
Room Temp
Staff Initials
8°F (-13.4°C)
7°F (-13.9°C)
6°F (-14.4°C)
5°F (-15.0°C)
4°F (-15.6°C)
3°F (-16.1°C)
2°F (-16.7°C)
1°F (-17.2°C)
0°F (-17.8°C)
-1°F (-18.3°C)
-2°F (-18.9°C)
-3°F (-19.4°C)
-4°F (-20.0°C)
-5°F (-20.6°C)
-6°F (-21.1°C)
-7°F to -57°F
≤-58°F (-50°C)
DATE
°F /°C
Action Taken: Fridge control adjusted, notified
Please list any steps
you've taken to address
1/1
33.1 °F
DOH etc.
temperature or storage
unit issues
If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-077 June 2020
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