OSDH Form 1112 "Vaccine Storage Incident Report (Vsir)" - Oklahoma

What Is ODH Form 1112?

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

Form Details:

  • Released on May 1, 2021;
  • The latest edition provided by the Oklahoma 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 ODH Form 1112 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 1112 "Vaccine Storage Incident Report (Vsir)" - Oklahoma

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2021 Vaccine Storage Incident Report (VSIR)
(For use when vaccine has been exposed to out of range temperatures. See VSIR Decision Tree)
Name of Clinic ___________________________________________________________ Date of Incident
VFC Pin #
Phone # __________________________ Assigned IFC
Contact Name
_________________________________
Email
Correct the situation. Adjust temperature control as appropriate, shut the door, plug in the refrigerator/freezer or transfer vaccine to a working
1.
storage unit with temperatures in the correct range and monitored by a data logger with a current certificate of calibration.
Contact Immunization Field Consultant (IFC) or if IFC is unavailable contact Immunization Service at 405-426-8580.
2.
Quarantine the vaccine. Bag and label the vaccine “DO NOT USE” so the vaccine is not administered until a response has been
received from Immunization Service. Keep the vaccine stored in a VFC approved storage unit at required temperatures until viability is
determined by Immunization Service. Do not automatically discard the affected vaccine.
3.
Record the following:
1.
Circle the units which were involved in the excursion.
Refrigerator
Freezer
Purpose built
Purpose built
Pharmaceutical grade
Pharmaceutical grade
2.
Circle the type of unit you have.
Stand-alone
Stand-alone
Household
Household
3.
Are the unit temperatures back within range?
Yes
No
Yes
No
4.
Has the vaccine previously been exposed to temperatures
Yes
No
Yes
No
outside the recommended range that resulted in a VSIR?
Min:
Max:
Min:
Max:
5.
What were the minimum and maximum temperatures?
°F
°F
°F
°F
6.
How long were the temperatures out of range?
Hrs:
Mins:
Hrs:
Mins:
Fill out the VSIR form completely. List the number of doses and lot number for only the vaccines which were involved in this excursion.
4.
Calculate the cost of the doses for each vaccine and record on the vaccine inventory form (page 2).
5.
Describe the incident in detail that resulted in vaccines being compromised. Describe actions taken to prevent a similar loss in the
future on the Vaccine Storage Incident Report Form (page 3).
6.
PROVIDER MUST sign the report. Fax the following documents to the assigned IFC at ________________________________
or email to _________________________________
Completed 3-Page Vaccine Storage Incident Report (VSIR)
Data logger data for excursion period
Temperature logs for excursion period
Any other related documents
*The VSIR will not be processed without a provider signature on page 3, or if all required documents are not submitted.
The IFC will contact the manufacturer regarding all vaccines which were exposed to out of range temperatures.
7.
8.
The provider IFC or Immunization Service will notify the contact name listed above regarding the determination of vaccine viability.
Vaccine must remain under quarantine until an official notification is provided by the IFC.
If the vaccines are determined to be nonviable, the provider should:
• Immediately remove the vaccine from the storage unit and mark it “Do Not Use”
• Set aside nonviable vaccine in a designated area until shipping label(s) arrive
• Complete the Vaccine Return Form and email to
VFCHelp@health.ok.gov
or fax to OSDH Immunization Service at 405-900-7612.
• Properly discard partial vials of vaccine
• Remove the spoiled vaccine from OSIIS Inventory
• Contact assigned IFC or Immunization Service at 405-426-8580 for assistance if needed.
ODH 1112
Oklahoma State Department of Health
Page 1 of 3
Revised 05/2021
Community Health Service Immunization Service/VFC
2021 Vaccine Storage Incident Report (VSIR)
(For use when vaccine has been exposed to out of range temperatures. See VSIR Decision Tree)
Name of Clinic ___________________________________________________________ Date of Incident
VFC Pin #
Phone # __________________________ Assigned IFC
Contact Name
_________________________________
Email
Correct the situation. Adjust temperature control as appropriate, shut the door, plug in the refrigerator/freezer or transfer vaccine to a working
1.
storage unit with temperatures in the correct range and monitored by a data logger with a current certificate of calibration.
Contact Immunization Field Consultant (IFC) or if IFC is unavailable contact Immunization Service at 405-426-8580.
2.
Quarantine the vaccine. Bag and label the vaccine “DO NOT USE” so the vaccine is not administered until a response has been
received from Immunization Service. Keep the vaccine stored in a VFC approved storage unit at required temperatures until viability is
determined by Immunization Service. Do not automatically discard the affected vaccine.
3.
Record the following:
1.
Circle the units which were involved in the excursion.
Refrigerator
Freezer
Purpose built
Purpose built
Pharmaceutical grade
Pharmaceutical grade
2.
Circle the type of unit you have.
Stand-alone
Stand-alone
Household
Household
3.
Are the unit temperatures back within range?
Yes
No
Yes
No
4.
Has the vaccine previously been exposed to temperatures
Yes
No
Yes
No
outside the recommended range that resulted in a VSIR?
Min:
Max:
Min:
Max:
5.
What were the minimum and maximum temperatures?
°F
°F
°F
°F
6.
How long were the temperatures out of range?
Hrs:
Mins:
Hrs:
Mins:
Fill out the VSIR form completely. List the number of doses and lot number for only the vaccines which were involved in this excursion.
4.
Calculate the cost of the doses for each vaccine and record on the vaccine inventory form (page 2).
5.
Describe the incident in detail that resulted in vaccines being compromised. Describe actions taken to prevent a similar loss in the
future on the Vaccine Storage Incident Report Form (page 3).
6.
PROVIDER MUST sign the report. Fax the following documents to the assigned IFC at ________________________________
or email to _________________________________
Completed 3-Page Vaccine Storage Incident Report (VSIR)
Data logger data for excursion period
Temperature logs for excursion period
Any other related documents
*The VSIR will not be processed without a provider signature on page 3, or if all required documents are not submitted.
The IFC will contact the manufacturer regarding all vaccines which were exposed to out of range temperatures.
7.
8.
The provider IFC or Immunization Service will notify the contact name listed above regarding the determination of vaccine viability.
Vaccine must remain under quarantine until an official notification is provided by the IFC.
If the vaccines are determined to be nonviable, the provider should:
• Immediately remove the vaccine from the storage unit and mark it “Do Not Use”
• Set aside nonviable vaccine in a designated area until shipping label(s) arrive
• Complete the Vaccine Return Form and email to
VFCHelp@health.ok.gov
or fax to OSDH Immunization Service at 405-900-7612.
• Properly discard partial vials of vaccine
• Remove the spoiled vaccine from OSIIS Inventory
• Contact assigned IFC or Immunization Service at 405-426-8580 for assistance if needed.
ODH 1112
Oklahoma State Department of Health
Page 1 of 3
Revised 05/2021
Community Health Service Immunization Service/VFC
Physical Count of Vaccine Inventory
Prices are subject to change/Replacement cost may be higher
Vaccine Brand Name
# of
Lot #2
# of Doses
Lot #1
Lot #3
# of Doses VFC Cost per Dose
Total Cost
DTaP (Daptacel)
$18.55
DTaP (Infanrix)
$19.16
DTaP/HepB/IPV(Pediarix)
$60.71
DTaP-IPV/Hib (Pentacel)
$61.65
DTaP-IPV (Kinrix)
$55.64
$16.02
Flucelvax 4y and up Syringes
$13.75
Fluarix 6m - 18 yrs Syringes
$13.75
FluLaval QD 6m and up Syringes
$13.55
Fluzone QD 6m and up MDV
Hep A Pediatric (Havrix)
$21.11
Hep A Pediatric (VAQTA)
$20.61
Hep B – Ped/Adol (ENGERIX)
$15.38
Hep B – Ped/Adol (Recombivax)
$12.53
Hib (ActHIB)
$9.75
Hib (PedvaxHIB)
$13.51
HPV 9(Gardasil 9)
$187.01
IPV (IPOL)
$13.85
Meningococcal B (Bexsero)
$120.24
Meningococcal B (Trumenba)
$114.36
Meningococcal Conjugate
$96.23
(M
)
Meningococcal Conjugate (Menveo)
$95.78
MMR (MMR II)
$21.70
MMR-V (ProQuad)
$137.51
Pneumococcal Conjugate (Prevnar)
$143.82
Pneumococcal Polysaccharide
$59.12
(P
)
Rotavirus (Rotarix)
$97.50
Rotavirus (Rotateq)
$70.49
Td (Tenivac)
$21.18
Tdap (BOOSTRIX)
$33.14
Tdap (ADACEL)
$32.63
Varicella (Varivax)
$109.26
Other
TOTAL OF ALL VACCINE
ODH 1112
Oklahoma State Department of Health
Page 2 of 3
Revised 05/2021
Community Health Service Immunization Service/VFC
Vaccine Storage Incident Report Form
Vaccine Storage and Handling Incident Category
1.
Weather related power outage
2.
Failure to store properly upon receipt
3.
Equipment malfunction
4.
Damaged or unaccounted for doses
5.
Failure to respond to out of range temperatures
6.
Other: _________________________________
Was the vaccine moved out of the primary unit? ☐ YES
☐ NO
Where do you store your MMR (MMR II) vaccine? ☐ Refrigerator ☐ Freezer
Detailed Description of the Incident: Please describe when, where, time and how the incident occurred.
Action Plan: What steps are being taken to ensure a similar loss does not occur in the future?
Signature:
Date:
Required Signature of Medical Director or Equivalent:
Date:
Page 3 of 3
Oklahoma State Department of Health
ODH 1112
Revised 05/2021
Community Health Service Immunization Service/VFC
Page of 3