Get Vaccine Return Form - Mississippi State Department Of Health - Msdh State Ms

Filling out the Vaccine Return Form is an essential process for clinics and healthcare providers returning unused or wasted vaccines. This guide offers step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the Vaccine Return Form

1. Press the ‘Get Form’ button to access the Vaccine Return Form and open it in your preferred editor.
2. Enter the date on which you are completing the form in the field labeled 'Date.' Use the format month/day/year.
3. In the 'Clinic Name' field, input the name of the health department or clinic that is returning the vaccine.
4. Provide the clinic’s state-assigned PIN number in the designated 'PIN' field.
5. Enter the complete mailing address of your clinic in the 'Mailing Address' section.
6. Specify the city associated with your mailing address in the 'City' field.
7. Input the telephone number of the individual completing the form in the 'Telephone Number' section.
8. Enter the name of the primary contact at your clinic in the 'Contact Name (Print)' field.
9. For each vaccine returned, fill in the details such as the 'Date' of wastage, the 'Vaccine' name, the 'Number of Doses' being returned, the 'Expiration Date', the 'Lot Number', the 'Return Code', and the 'Nurse’s Initials'.
10. Sign and date the form by adding your contact name, signature, and the date at the bottom of the form.
11. Once all the fields are completed, save changes, download, print, or share the completed Vaccine Return Form as necessary.

Complete and submit your Vaccine Return Form online to ensure your clinic is compliant and manage vaccine returns effectively.