Form 670F "Temperature Log for Freezer - Fahrenheit" - Mississippi

What Is Form 670F?

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

Form Details:

  • Released on January 17, 2019;
  • The latest edition provided by the Mississippi 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 670F by clicking the link below or browse more documents and templates provided by the Mississippi Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form 670F "Temperature Log for Freezer - Fahrenheit" - Mississippi

Download PDF

Fill PDF online

Rate (4.8 / 5) 10 votes
Temperature Log for Freezer – Fahrenheit
F
°
Month
/
Year
VFC PIN or other ID #
Page 1 of 3
DAYS 1 – 15
Facility Name
Take action if temp is out of range—too warm (above 5ºF) or too cold (below - 58ºF).
Monitor temperatures closely!
1. Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
1. Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
2. If using temperature monitoring device (TMD; digital data logger recommended)
Do not discard vaccines unless directed to by your state/local health department and/or the
that records min/max temps, document min/max once each workday, preferably in
manufacturer(s).
the morning. If using TMD that does not record min/max temps, document current
2. Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
temps twice, at beginning and end of each workday.
3. Notify your vaccine coordinator, or call the immunization program at your state or local health
3. Put an “X” in the row that corresponds to the freezer’s temperature.
department for guidance.
4. If any out-of-range temp, see instructions to the right.
4. Document the action taken on the “Vaccine Storage Troubleshooting Record” on page 3.
5. After each month has ended, save each month’s log for 3 years, unless state/local
jurisdictions require a longer period.
Day of Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Staff Initials
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
Min/Max Temp in Unit
(since previous reading)
Danger! Temperatures above 5ºF are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!
5°F
4°F
3°F
2°F
1°F
0°F
- 1°F
- 2°F
- 3°F
- 4°F
- 58°F to - 5°F
Write any out-of-range
temps (above 5ºF
or below - 58ºF) here.
Room Temperature
If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3.
www.immunize.org/catg.d/p3038F.pdf • Item #P3038F (8/18)
_____________________________________________________
Signature
Mississippi State Department of Health
Revised 1/17/19
Form 670F
Temperature Log for Freezer – Fahrenheit
F
°
Month
/
Year
VFC PIN or other ID #
Page 1 of 3
DAYS 1 – 15
Facility Name
Take action if temp is out of range—too warm (above 5ºF) or too cold (below - 58ºF).
Monitor temperatures closely!
1. Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
1. Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
2. If using temperature monitoring device (TMD; digital data logger recommended)
Do not discard vaccines unless directed to by your state/local health department and/or the
that records min/max temps, document min/max once each workday, preferably in
manufacturer(s).
the morning. If using TMD that does not record min/max temps, document current
2. Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
temps twice, at beginning and end of each workday.
3. Notify your vaccine coordinator, or call the immunization program at your state or local health
3. Put an “X” in the row that corresponds to the freezer’s temperature.
department for guidance.
4. If any out-of-range temp, see instructions to the right.
4. Document the action taken on the “Vaccine Storage Troubleshooting Record” on page 3.
5. After each month has ended, save each month’s log for 3 years, unless state/local
jurisdictions require a longer period.
Day of Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Staff Initials
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
Min/Max Temp in Unit
(since previous reading)
Danger! Temperatures above 5ºF are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!
5°F
4°F
3°F
2°F
1°F
0°F
- 1°F
- 2°F
- 3°F
- 4°F
- 58°F to - 5°F
Write any out-of-range
temps (above 5ºF
or below - 58ºF) here.
Room Temperature
If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3.
www.immunize.org/catg.d/p3038F.pdf • Item #P3038F (8/18)
_____________________________________________________
Signature
Mississippi State Department of Health
Revised 1/17/19
Form 670F
Temperature Log for Freezer – Fahrenheit
F
°
Month
/
Year
VFC PIN or other ID #
Page 2 of 3
DAYS 16 – 31
Facility Name
Take action if temp is out of range – too warm (above 5ºF) or too cold (below - 58ºF).
Monitor temperatures closely!
1. Write your initials below in “Staff Initials,” and note the time in “Exact Time.”
1. Label exposed vaccine “do not use,” and store it under proper conditions as quickly as possible.
2. If using temperature monitoring device (TMD; digital data logger recommended)
Do not discard vaccines unless directed to by your state/local health department and/or the
that records min/max temps, document min/max once each workday, preferably in
manufacturer(s).
the morning. If using TMD that does not record min/max temps, document current
2. Record the out-of-range temps and the room temp in the “Action” area on the bottom of the log.
temps twice, at beginning and end of each workday.
3. Notify your vaccine coordinator, or call the immunization program at your state or local health
3. Put an “X” in the row that corresponds to the freezer’s temperature.
department for guidance.
4. If any out-of-range temp, see instructions to the right.
4. Document the action taken on the “Vaccine Storage Troubleshooting Record” on page 3.
5. After each month has ended, save each month’s log for 3 years, unless state/local
jurisdictions require a longer period.
Day of Month
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Staff Initials
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
Min/Max Temp in Unit
(since previous reading)
Danger! Temperatures above 5°F are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!
5°F
4°F
3°F
2°F
1°F
0°F
- 1°F
- 2°F
- 3°F
- 4°F
- 58°F to - 5°F
Write any out-of-range
temps (above 5ºF or
below -58°F) here.
Room Temperature
If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3.
www.immunize.org/catg.d/p3038F.pdf • Item #P3038F (8/18)
_____________________________________________________
Signature
Mississippi State Department of Health
Revised 1/17/19
Form 670F
Vaccine Storage Troubleshooting Record
□Refrigerator □Freezer
(check one)
Page 3 of 3
Use this form to document any unacceptable vaccine storage event, such as exposure of refrigerated vaccines to temperatures that are outside the manufacturers' recommended storage ranges.
A fillable troubleshooting record (i.e., editable PDF) can also be found at www.immunize.org/clinic/storage-handling.asp.
Date & Time of Event
Storage Unit Temperature
Room Temperature
Person Completing Report
If multiple, related events occurred,
at the time the problem was discovered
at the time the problem was discovered
see Description of Event below.
Date:
Temp when discovered:
Temp when discovered:
Name:
Time:
Minimum temp:
Maximum temp:
Comment (optional):
Title:
Date:
Description of Event
(If multiple, related events occurred, list each date, time, and length of time out of storage.)
• General description (i.e., what happened?)
• Estimated length of time between event and last documented reading of storage temperature in acceptable range (2
o
to 8
o
C [36
o
to 46
o
F] for refrigerator; -50
o
to -15
o
C [-58º to 5ºF] for freezer)
• Inventory of affected vaccines, including (1) lot #s and (2) whether purchased with public (for example, VFC) or private funds (Use separate sheet if needed, but maintain the inventory with this troubleshooting record.)
• At the time of the event, what else was in the storage unit? For example, were there water bottles in the refrigerator and/or frozen coolant packs in the freezer?
• Prior to this event, have there been any storage problems with this unit and/or with the affected vaccine?
• Include any other information you feel might be relevant to understanding the event.
Action Taken
(Document thoroughly. This information is critical to determining whether the vaccine might still be viable!)
• When were the affected vaccines placed in proper storage conditions? (Note: Do not discard the vaccine. Store exposed vaccine in proper conditions and label it “do not use” until after you can discuss with your state/
local health department and/or the manufacturer[s].)
• Who was contacted regarding the incident? (For example, supervisor, state/local health department, manufacturer—list all.)
• IMPORTANT: What did you do to prevent a similar problem from occurring in the future?
Results
• What happened to the vaccine? Was it able to be used? If not, was it returned to the distributor? (Note: For public-purchase vaccine, follow your state/local health department instructions for vaccine disposition.)
www.immunize.org/catg.d/p3041.pdf • Item #P3041 (8
/
18)
Mississippi State Department of Health
Revised 1/17/19
Form 670F
Vaccine Storage Troubleshooting Record
□Refrigerator □Freezer
(check one)
Use this form to document any unacceptable vaccine storage event, such as exposure of refrigerated vaccines to temperatures that are outside the manufacturers' recommended storage ranges.
A fillable troubleshooting record (i.e., editable pdf) can also be found at www.immunize.org/clinic/storage-handling.asp
Date & Time of Event
Storage Unit Temperature
Room Temperature
Person Completing Report
If multiple, related events occurred,
at the time the problem was discovered
at the time the problem was discovered
see Description of Event below.
Date: 7/16/2018
Temp when discovered: 55ºF
Temp when discovered: 77ºF
Name: Nancy Nurse
Time: 8:00 am
Minimum temp: 2ºF
Maximum temp: 57ºF
Title: VFC Coordinator
Date: 7/17/18
temp is approx
Comment (optional):
Description of Event
(If multiple, related events occurred, list each date, time, and length of time out of storage.)
• General description (i.e., what happened?)
• Estimated length of time between event & last documented reading of storage temperature in acceptable range (2
o
to 8
o
C [36
o
to 46
o
F] for refrigerator; -50
o
to -15
o
C [-58º to 5ºF] for freezer)
• Inventory of affected vaccines, including (1) lot #s and (2) whether purchased with public (for example, VFC) or private funds (Use separate sheet if needed, but maintain the inventory with this troubleshooting record)
• At the time of the event, what else was in the storage unit? For example, were there water bottles in the refrigerator and/or frozen coolant packs in the freezer?
• Prior to this event, have there been any storage problems with this unit and/or with the affected vaccine?
• Include any other information you feel might be relevant to understanding the event.
When checked vaccine freezer (in lab) at 8:00 am on Tuesday, 7/17/2018, discovered freezer door slightly ajar. Digital readout on data logger
read 55°F. Data logger located in center of freezer with probe in glycol . Review of computer readings (taken every 15 minutes) showed steady rise
in temps from 2°F at 5:30 pm (7/16/2018) to 55°F reading discovered when arrived at clinic on Tuesday morning (7/17/2018). Readings hit
6°F at 11 pm (7/16) and 45°F at 2 am (7/17). Total time out of recommended storage temp of 5°F or below = 9 hours. (See attached document of
continuous temp readings.) Freezer contained Varivax, ProQuad , and Zostavax (inventory attached).
Frozen packs stored on freezer floor and shelves in door. No recent adjustments to temp controls and no previous temp excursions noted with this
freezer before 7/17.
Action Taken
(Document thoroughly. This information is critical to determining whether the vaccine might still be viable!)
• When were the affected vaccines placed in proper storage conditions? (Note: Do not discard the vaccine. Store exposed vaccine in proper conditions and label it “do not use” until after you can discuss with your
state/local health department and/or the manufacturer[s].)
• Who was contacted regarding the incident? (For example, supervisor, state/local health department, manufacturer—list all.)
• IMPORTANT: What did you do to prevent a similar problem from occurring in the future?
Upon discovery, vaccines marked “Do Not Use” and stored in 2nd clinic freezer (in exam room #3) at 1°F. Also placed “Do Not Use” note on main
freezer in lab. Notified Susie Supervisor about the issue . Contacted Victor Vaccine at My State Immunization Program at 8:30 am. Provided Victor
with details of event and list of vaccines in freezer. Victor said to maintain vaccines in 2nd freezer and that he would check with Merck (manufac-
turer of all the affected vaccines) to determine next steps. Called Jim’s Appliance Repair to examine freezer. Repairman replaced freezer door gasket
and recommended removal of ~½ of freezer packs in door because size and weight of packs potentially interfered with door closing completely. No
problems identified with thermostat or other mechanical components.
Removed half of freezer packs located in shelf in door, per recommendation . Reset data logger on center shelf of freezer with probe in glycol . All
staff received refresher training on ensuring freezer door is closed after each use , and a reminder sign was placed prominently on freezer door.
Results
• What happened to the vaccine? Was it able to be used? If not, was it returned to the distributor? (Note: For public-purchase vaccine, follow your state/local health department instructions for vaccine disposition.)
After repair, monitored temps in empty freezer for 1 week , per state requirements. Freezer maintained 0–2°F temps for entire week . Submitted repair
documentation and data logger readings to Victor Vaccine for approval and ordered replacement vaccines. Victor had checked with manufacturer.
After reviewing history and stability data, manufacturer stated vaccine was acceptable for continued use . Discussed entire situation with Susie
Supervisor and clinic director, Dr. Immunize , who agreed on continued use of vaccine . Vaccine to be labeled as "use first."
distributed by the
Technical content reviewed by the Centers for Disease Control and Prevention
Immunization Action Coalition
651 - 647 - 9009
Saint Paul, Minnesota
www.immunize.org
www.vaccineinformation.org
www.immunize.org/catg.d/p3041.pdf • Item #P3041 (8
18)
/
Page of 6