"Vaccine Management Plan Form" - Missouri

Vaccine Management Plan 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 October 1, 2018;
  • 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 fillable 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 Management Plan Form" - Missouri

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Missouri Department of Health and Senior Services
Vaccines for Children Program
Vaccine Management
Plan
Th e Vaccine Management Plan follows the “Vaccine Management Guidance” found in the VFC program
manual. It provides guidance on vaccine storage and handling, vaccine ordering, vaccine shipments,
vacine inventory control and vaccine wastage plans. You must complete and remit a copy of this plan.
FACILITY INFORMATION
Facility Name:
VFC PIN:
Primary Vaccine Coordinator:
Phone:
Cell:
Back-Up Vaccine Coordinator:
Phone:
Cell:
VACCINE STORAGE AND HANDLING
Responsibilities Include:
Will only open one box of vaccine at a time.
Will not “dump” vaccine into other containers (even if they are the same vaccine).
Check and use vaccine within time frames specif ed by manufacturer’s labeling and recommendations prior to administration.
Ensure vaccines are not “pre-drawn” from their vials.
Ensure vaccines are kept away from sides and back of the refrigerator.
Remove produce drawers and place bottles of water in that space.
Ensure vaccines are not stored in the door of the refrigerator and place bottles of water in that space.
Line the freezer sides and f oor with ice packs.
Regularly check all storage units to ensure adequate air circulation is occurring around vaccine and that vaccine has
not been placed in closed bins (such as the plastic closed containers supplied by drug manufacturer representatives).
Take appropriate steps to ensure refrigerators and freezers are not unplugged accidentally, the “Do Not Unplug” sticker is
visible, and the use of plug guards or other means to secure plugs are in place.
Ensure that units are plugged directly into outlets and not into power strips or extension cords.
Identify and label the circuit breakers for the vaccine refrigerators and freezers using the “Do Not Turn Off” stickers or similar
labeling.
Ensure that all staff are prof cient in their ability to properly pack vaccine for transfer or emergency shipping.
Ensure that all staff are prof cient in their ability to read data loggers, know correct temperature ranges, and can properly record
temperatures on correct (F or C) temperature log sheets or enter for submitting via VOS.
Ensure that temperatures are taken twice per day AM/PM when clinic is open and logged on an appropriate (F or C)
temperature log or entered for submitting via VOS.
VFC off ce coordinator or designee will record temperatures daily. Temperature logs that contain out-of-range temperatures that
are marked “Yes” indicating temperature was within range, is considered negligence.
If at any time there is a break in the cold chain the VFC program is to be immediately notif ed and provided with the completed
Emergency Response Worksheet.
Ensure that all required VFC monthly reports are submitted to the VFC program on time via VOS.
Maintain a simple training log documenting staff training.
VACCINE ORDERING
Responsibilities Include:
Ensure that all orders are made by ordering the number of vaccine doses needed, not the number of boxes.
Ensure that if more than one vaccine manufacturer is available, order one brand as much as possible to lessen administration
and accounting errors.
Ensure that all orders include VFC PIN and provider name.
Ensure that the vaccine ordered is only to maintain approximately a 30-45 day supply of vaccine.
Ensure that the vaccine orders, accountabilities, and temperature logs are submitted electronically via VOS or paper.
1
Rev 10/18
Bureau of Immunizations • PO Box 570 • Jefferson City, MO 65102 • 800.219.3224
Missouri Department of Health and Senior Services
Vaccines for Children Program
Vaccine Management
Plan
Th e Vaccine Management Plan follows the “Vaccine Management Guidance” found in the VFC program
manual. It provides guidance on vaccine storage and handling, vaccine ordering, vaccine shipments,
vacine inventory control and vaccine wastage plans. You must complete and remit a copy of this plan.
FACILITY INFORMATION
Facility Name:
VFC PIN:
Primary Vaccine Coordinator:
Phone:
Cell:
Back-Up Vaccine Coordinator:
Phone:
Cell:
VACCINE STORAGE AND HANDLING
Responsibilities Include:
Will only open one box of vaccine at a time.
Will not “dump” vaccine into other containers (even if they are the same vaccine).
Check and use vaccine within time frames specif ed by manufacturer’s labeling and recommendations prior to administration.
Ensure vaccines are not “pre-drawn” from their vials.
Ensure vaccines are kept away from sides and back of the refrigerator.
Remove produce drawers and place bottles of water in that space.
Ensure vaccines are not stored in the door of the refrigerator and place bottles of water in that space.
Line the freezer sides and f oor with ice packs.
Regularly check all storage units to ensure adequate air circulation is occurring around vaccine and that vaccine has
not been placed in closed bins (such as the plastic closed containers supplied by drug manufacturer representatives).
Take appropriate steps to ensure refrigerators and freezers are not unplugged accidentally, the “Do Not Unplug” sticker is
visible, and the use of plug guards or other means to secure plugs are in place.
Ensure that units are plugged directly into outlets and not into power strips or extension cords.
Identify and label the circuit breakers for the vaccine refrigerators and freezers using the “Do Not Turn Off” stickers or similar
labeling.
Ensure that all staff are prof cient in their ability to properly pack vaccine for transfer or emergency shipping.
Ensure that all staff are prof cient in their ability to read data loggers, know correct temperature ranges, and can properly record
temperatures on correct (F or C) temperature log sheets or enter for submitting via VOS.
Ensure that temperatures are taken twice per day AM/PM when clinic is open and logged on an appropriate (F or C)
temperature log or entered for submitting via VOS.
VFC off ce coordinator or designee will record temperatures daily. Temperature logs that contain out-of-range temperatures that
are marked “Yes” indicating temperature was within range, is considered negligence.
If at any time there is a break in the cold chain the VFC program is to be immediately notif ed and provided with the completed
Emergency Response Worksheet.
Ensure that all required VFC monthly reports are submitted to the VFC program on time via VOS.
Maintain a simple training log documenting staff training.
VACCINE ORDERING
Responsibilities Include:
Ensure that all orders are made by ordering the number of vaccine doses needed, not the number of boxes.
Ensure that if more than one vaccine manufacturer is available, order one brand as much as possible to lessen administration
and accounting errors.
Ensure that all orders include VFC PIN and provider name.
Ensure that the vaccine ordered is only to maintain approximately a 30-45 day supply of vaccine.
Ensure that the vaccine orders, accountabilities, and temperature logs are submitted electronically via VOS or paper.
1
Rev 10/18
Bureau of Immunizations • PO Box 570 • Jefferson City, MO 65102 • 800.219.3224
Vaccine Management Plan
VACCINE ORDERING
(CONTINUED)
Ensure that all vaccine orders are submitted properly with required documentation.
Temperature logs are to be documented from the f rst day of the month through the close of business the last day of the month.
Temperarure logs are due to the the VFC program the f rst business day of every month.
Ensure that all monthly reports are submitted within the assigned ordering schedule to assure provider remains in good
standing and orders can be processed without delay.
VACCINE SHIPMENTS
Responsibilities for Receiving Include:
Upon receipt of vaccine, immediately examine all vaccine shipments for damage, or opening prior to receipt, contacting the VFC
program within two hours of delivery if abnormalities are noted.
Immediately open the shipping box and count vaccines received, comparing the numbers against shipping invoice and order
form, checking the temperature indicator to ensure vaccine cold chain has been maintained, contacting the VFC program within
two hours of delivery if abnormalities are noted.
Immediately store vaccines in the appropriate refrigeration storage units, checking expiration dates and placing the order
received in the proper stock rotation to assure vaccines with the shortest expiration date are used f rst.
Maintain vaccine packing slip from manufacturers for three years.
VFC Highly Recommends:
Documenting the date and time your order was received on packing slip.
Writing the expiration date in black marker on top of vaccine box.
Taping boxes of vaccine shut that are not already secured by the manufacturer to avoid opening more than one box of vaccine
at a time and to help facilitate your monthly vaccine inventory count.
INVENTORY CONTROL
(INCLUDES STOCK ROTATION & VACCINE TRANSFER)
Responsibilities Include:
Check expiration dates monthly.
Put the expiration date on the box so it is easily visible yet not obscuring vital vaccine information on the box.
Rotate vaccine as needed to ensure that the shortest expiration dated vaccine is used fi rst
Ensure that vaccine does not expire.
If expiration date is within 90 days, contact the local public health agency and a minimum of two other VFC provider to see if
they will accept a transfer.
Before transfer is made, contact the VFC program at 800.219.3224 for transfer approval.
Responsibilities for Vaccine Transfers Include:
Contact the VFC program at 800.219.3224 prior to transfers.
Transport vaccine per the Emergency Reponse Plan: Transport Vaccine Procedures. Ensure vaccine is properly packed.
Complete a Vaccine Transfer form to take with the vaccine to the new location. Upon arrival open the containers, record the
temperatures, inventory the stock (with the receiving person) and see that the receiving person places vaccines in the proper
refrigeration units, which are maintained at the proper temperature ranges. If vaccine has been placed in a closed zip lock bag
for transfer, remove from zip lock bag and place in storage units.
After transfer is complete, submit the transfer electronically via VOS or fax a copy of the completed Vaccine Transfer form to the
VFC program at 573.526.5220.
2
Rev 10/18
Bureau of Immunizations • PO Box 570 • Jefferson City, MO 65102 • 800.219.3224
Vaccine Management Plan
VACCINE WASTAGE
Responsibilities Include:
In the event that vaccine is wasted, the wastage must be reported to the VFC program. Wastage can be reported electronically
via a VOS wastage or return form or fax a copy of the completed Vaccine Wastage and Return form to the VFC program at
573.526.5220.
Upon receipt of a wastage report your VFC liaison will process the wastage form, which will generate a Vaccine Return ID and
request a pre-paid return label from McKesson for all returnable vaccine. You will be emailed or faxed a copy of the Vaccine
Return ID, which must be included with the vaccine being returned. The vaccine in the box and the vaccine listed on the Vaccine
Return ID need to match.
Ensure the wastage vaccine amounts are deducted from your monthly SMV inventory and dosage or vaccine accountability form
submitted to the VFC program. Vaccine that is unaccounted for will be considered wastage and is subject to replacement.
ALL wastage must be entered in VOS prior to submitting monthly inventory and dosage forms.
You will be held fi nancially responsible for replacing vaccine doses due to negligence if the above
procedures are not followed.
__________________________________________________________________________________
Signature:
Medical License Number: _____________________________________________ Date: __________________________
By signing your name, entering your medical license number and date, you, on behalf of yourself and all practitioners
associated with this medical offi ce, group practice, health department, specialty clinic, hospital or other entity of
which you are the physician-in-charge, medical director or equivalent, agree to comply with each of the VFC program
requirements.
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Bureau of Immunizations • PO Box 570 • Jefferson City, MO 65102 • 800.219.3224
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