Get Vaccine Incident Report And Return Form Please Fax The ... - Co Whatcom Wa

Filling out the Vaccine Incident Report and Return Form is essential for health care providers participating in the Washington State vaccine program. This guide provides a step-by-step approach to help you navigate through the form with ease.

Follow the steps to complete the Vaccine Incident Report and Return Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date in the designated field.
3. Fill in your vaccine ordering PIN in the corresponding space provided.
4. Complete the provider/clinic name and all relevant address fields, ensuring to include city, state, and zip code.
5. Provide your contact name along with the name of the Local Health Jurisdiction (LHJ) you are associated with.
6. Input your telephone number and the date when you contacted your LHJ.
7. Record the number of doses, vaccine product details, and the reason for the vaccine incident, using the last pages for additional lot numbers if necessary.
8. If applicable, for all incidents except expired seasonal and H1N1 flu vaccines, describe the reason for the vaccine incident and include corrective actions taken to prevent recurrence.
9. If the incident is a spoiled vaccine, answer the questions regarding exposure to out-of-range temperatures, detailing duration and circumstances.
10. Fill out any additional lot numbers if necessary and ensure all sections of the form are complete.
11. After reviewing the form for accuracy, you can save changes, download, print, or share the completed form.

Start filling out your Vaccine Incident Report and Return Form online today!