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Get Massachusetts Vaccine Transfer Form

Massachusetts Department of Public Health Division of Epidemiology and Immunization VFC Vaccine Transfer Form Guidance Vaccine loss due to expiration is frequently a consequence of over ordering poor inventory management or low volume usage. VFC-enrolled providers are expected to check their current vaccine inventory expiration dates monthly. If short dated vaccine vaccine due to expire in 2 months is found the vaccine may be transferred to another provider so that it may be used prior to expiration* MDPH instituted a Vaccine Restitution Policy effective January 1 2011 which requires providers to make restitution for any federal or state purchased vaccines that have been lost due to provider s failure to properly receive store or handle vaccine inventory. This includes failure to rotate vaccine stock resulting in expired vaccine. It is the provider s responsibility to locate another pediatric practice and transfer short dated vaccine. If the provider is unable to locate a pediatric practice in their area call the Vaccine Unit for assistance. 617-983-6828 Directions for use of this form Refrigerated vaccine must be transported in a cooler with cold packs not freezer packs. Providers must fill out the VFC Vaccine Transfer Form and fax to the Vaccine Unit 617-983-6924. Both providers should keep a signed copy of the completed form in their office records. Fax the completed form to 617-983-6924 ATTN MDPH Vaccine Unit Transferred from-Provider Name Provider Site Number Office Contact Name Tel Transferred to-Provider Name Provider Site Number Vaccine Number of Doses Lot and Expiration Date Reason for short dated vaccine circle one 1. Low volume use 2. Over ordering 3. Not rotating stock 4. Other specify Recipient Provider Signature Vaccine-Management-transfer-form*doc circle one Date March 2013. VFC-enrolled providers are expected to check their current vaccine inventory expiration dates monthly. If short dated vaccine vaccine due to expire in 2 months is found the vaccine may be transferred to another provider so that it may be used prior to expiration* MDPH instituted a Vaccine Restitution Policy effective January 1 2011 which requires providers to make restitution for any federal or state purchased vaccines that have been lost due to provider s failure to properly receive store or handle vaccine inventory. If short dated vaccine vaccine due to expire in 2 months is found the vaccine may be transferred to another provider so that it may be used prior to expiration* MDPH instituted a Vaccine Restitution Policy effective January 1 2011 which requires providers to make restitution for any federal or state purchased vaccines that have been lost due to provider s failure to properly receive store or handle vaccine inventory. This includes failure to rotate vaccine stock resulting in expired vaccine. It is the provider s responsibility to locate another pediatric practice and transfer short dated vaccine. This includes failure to rotate vaccine stock resulting in expired vaccine. It is the provider s responsibility to locate another pediatric practice and transfer short dated vaccine. If the provider is unable to locate a pediatric practice in their area call the Vaccine Unit for assistance.

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