"Vaccine Transfer Form" - Missouri

Vaccine Transfer Form is a legal document that was released by the Missouri Department of Health and Senior Services - a government authority operating within Missouri.

Form Details:

  • Released on March 1, 2014;
  • The latest edition currently provided by the Missouri Department of Health and Senior Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Missouri Department of Health and Senior Services.

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Download "Vaccine Transfer Form" - Missouri

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V
C
P
ACCINES FOR
HILDREN
ROGRAM
Vaccine Transfer Form
Transferring Vaccines for Children (VFC)-funded vaccine to another VFC clinic should not be a routine practice. Providers should monitor vaccine inventory and
usage patterns closely to ensure vaccine transfer is an infrequent occurrence. Vaccines should be transferred at least 3 months before expiration date, if possible.
Instructions:
Call the VFC program at 800-219-3224 for transfer approval. VFC program approval MUST BE given prior to vaccine transfer.
Follow VFC and manufacturer specifications for maintaining vaccine within the recommended temperature range during the transport of vaccine.
Only full, sealed vials or unopened prefilled syringes can be transferred.
Local Public Health Agencies may only transfer adult vaccine to another Local Public Health Agency.
Complete this form when transferring vaccines to another facility and submit to the VFC program on the transfer date.
Name of BIAA Staff Member Who Approved Vaccine Transfer
Date BIAA Staff Member Gave Vaccine Transfer Approval
Name and Signature of Person Transferring Vaccine
VFC PIN
Name and Signature of Person Receiving Vaccine
VFC PIN
INDICATE REASON FOR TRANSFER (CHOOSE ONE)
DATE OF TRANSFER
COMPLIANCE ISSUE
NO LONGER IN VFC PROGRAM
OTHER
DISEASE OUTBREAK
OVERSHIPMENT
VACCINE STORAGE
VACCINE BRAND
NDC #
LOT #
EXPIRATION DATE
NUMBER OF DOSES
Missouri Department of Health and Senior Services
Bureau of Immunization Assessment and Assurance  930 Wildwood Drive  Jefferson City, MO  65109
800.219.3224  Fax: 573.526.5220
Rev 3-14
V
C
P
ACCINES FOR
HILDREN
ROGRAM
Vaccine Transfer Form
Transferring Vaccines for Children (VFC)-funded vaccine to another VFC clinic should not be a routine practice. Providers should monitor vaccine inventory and
usage patterns closely to ensure vaccine transfer is an infrequent occurrence. Vaccines should be transferred at least 3 months before expiration date, if possible.
Instructions:
Call the VFC program at 800-219-3224 for transfer approval. VFC program approval MUST BE given prior to vaccine transfer.
Follow VFC and manufacturer specifications for maintaining vaccine within the recommended temperature range during the transport of vaccine.
Only full, sealed vials or unopened prefilled syringes can be transferred.
Local Public Health Agencies may only transfer adult vaccine to another Local Public Health Agency.
Complete this form when transferring vaccines to another facility and submit to the VFC program on the transfer date.
Name of BIAA Staff Member Who Approved Vaccine Transfer
Date BIAA Staff Member Gave Vaccine Transfer Approval
Name and Signature of Person Transferring Vaccine
VFC PIN
Name and Signature of Person Receiving Vaccine
VFC PIN
INDICATE REASON FOR TRANSFER (CHOOSE ONE)
DATE OF TRANSFER
COMPLIANCE ISSUE
NO LONGER IN VFC PROGRAM
OTHER
DISEASE OUTBREAK
OVERSHIPMENT
VACCINE STORAGE
VACCINE BRAND
NDC #
LOT #
EXPIRATION DATE
NUMBER OF DOSES
Missouri Department of Health and Senior Services
Bureau of Immunization Assessment and Assurance  930 Wildwood Drive  Jefferson City, MO  65109
800.219.3224  Fax: 573.526.5220
Rev 3-14