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Vaccine Storage Contingency Plan Facility Name TVFC PIN Address Date City State Zip Code Phone Clinic staff responsible for transfer of vaccine Phone number Name Name back-up Transfer vaccine to Address Generator Contact Name Date of agreement Where to obtain Yes No Ice Dry ice Cooler Shipping Agent Tracking number Contact with LHD/HSR made prior to transport by Transport of refrigerated vaccine checklist Temperature of refrigerator prior to transport Inventory of vaccine use C-33 and included in bag with vaccine. Keep a copy for your records. Bag labeled with PIN clinic name clinic contact phone number. Container used to transport refrigerated vaccine Ice packs are in container separated from vaccine by crumpled paper. Thermometer in container. Time and temperature in container prior to transport Person transporting vaccine Varicella packed in dry ice. In the event of a city-wide evacuation contact your health service region for evacuation plan* Texas Department of State Health Services Immunization Branch Stock No* 11-11190 Rev* 07/2007. Keep a copy for your records. Bag labeled with PIN clinic name clinic contact phone number. Container used to transport refrigerated vaccine Ice packs are in container separated from vaccine by crumpled paper. Thermometer in container. Time and temperature in container prior to transport Person transporting vaccine Varicella packed in dry ice. Thermometer in container. Time and temperature in container prior to transport Person transporting vaccine Varicella packed in dry ice. In the event of a city-wide evacuation contact your health service region for evacuation plan* Texas Department of State Health Services Immunization Branch Stock No* 11-11190 Rev* 07/2007. Keep a copy for your records. Bag labeled with PIN clinic name clinic contact phone number. Container used to transport refrigerated vaccine Ice packs are in container separated from vaccine by crumpled paper. Thermometer in container. Time and temperature in container prior to transport Person transporting vaccine Varicella packed in dry ice. In the event of a city-wide evacuation contact your health service region for evacuation plan* Texas Department of State Health Services Immunization Branch Stock No* 11-11190 Rev* 07/2007.

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