Mississippi State Department of Health Vaccine Return Form

Mississippi State Department of Health
Vaccine Return Form
The clinic will be financially responsible for annual vaccine
lost/wasted greater than 5%.
2. Clinic Name
1. _______________________
3. PIN
4. Shipping Address
Date
5. City
IMPORTANT
✓ Fax a copy to: 601-576-7686
Mississippi State Department of Health
6. Telephone Number
Immunization Program
570 East Woodrow Wilson
7. Contact Name (Print)
Post Office Box 1700
Jackson, Mississippi 39215-1700
✓ Keep a copy for your file
8. E-Mail Address
✓ Include a copy with vaccine product
to be returned
✓ NOTE: For MSDH health departments, this form may be used to document adult vaccine returns to the pharmacy. Fill out the form as
instructed except use adult as the funding source; send vaccine and one copy of the completed form to the MSDH Pharmacy.
Return Code:
1. Refrigerator malfunction (temp. at discovery.) 2. Left Out of Refrigerator/Freezer
6. Power Outage
Date
7. Natural Disaster
Vaccine
3. Expired Vaccine
4. Damaged in Transit 5. Vaccine Recall
8. Other ____________
*Number
of Doses
Expiration
Date
Lot
Number
NDC#
Number
Funding Source
(VFC, CHIP
Return
Code
Nurses
Signature
State Ped,
or 317)
___________________________________________________
__________________________
Contact Name Signature
Date
*Amounts entered on form must match what is being entered into MIIX.
*Amounts entered on form must match amount of vaccine placed in shipping box for return to McKesson.
Mississippi State Department of Health
Revised 02-12-16
Form 131
Instructions for Vaccine Return Form
(Form No. 131)
Purpose
The Vaccine Return Form is used to document the amount of vaccine being returned by each health
department clinic or vaccine provider and the reason for its return.
Instructions
Returns: Each unopened dose of vaccine that cannot be administered to patients must be returned to
the distributor. Clinic staff should complete a Vaccine Return Form and fax the form to the Immunization
Program. The Immunization Program staff will arrange for the distributor to send the clinic a return shipping
label by e-mail or mail or arrange for pick-up from the clinic location. DO NOT RETURN VACCINE TO
THE IMMUNIZATION PROGRAM. A copy of the return form must be enclosed in the shipping container
with the vaccine and a copy of the form should be retained for the clinic’s file. The return shipping label
should be adhered to the outside of the box. If the box has not been picked up from the clinic location
within 2 weeks of receipt of the shipping label, contact the Immunization Program by phone at
(601) 576-7751. Clinic staff must make every effort to minimize vaccine returns through proper ordering,
storage, handling, and administration. The clinic will be financially responsible for annual vaccine loss
greater than 5% in the clinic.
Note: Amounts entered on the form should match what is being returned and entered in MIIX.
1. Date: Enter the date (mo/day/yr) the report is being completed.
2. Health Department/Clinic Name: Enter the name of the health department or clinic that is returning
the vaccine.
3. PIN: Enter the clinic’s VFC PIN number.
4. Shipping Address: Enter the complete shipping address of the clinic.
5. City: Enter the city corresponding with the address.
6. Telephone Number: Enter the telephone number of the person completing this report.
7. Contact Name: Print the name of the contact person for the clinic/ facility.
8. E-Mail Address: Enter the E-mail address of the contact person for the clinic/facility.
All other columns are to be completed by vaccine type as follows:
• Date: Enter the date (mo/day/yr) the vaccine was packaged for return.
• Vaccine: Enter the name of the vaccine being returned.
• Number of Doses: Enter the number of doses being returned.
• Expiration Date: Enter the expiration date (mo/day/yr) of the vaccine that is being returned.
• Lot Number: Enter the lot number of the vaccine that is being returned.
• NDC #: Enter the NDC number of the vaccine being returned.
• Funding Source: Enter the funding source (VFC, CHIP, State Ped, or 317) for the vaccine
being returned. Note: Use adult funding source if using the form for MSDH pharmacy adult
vaccine returns.
• Return Code: Enter the reason for the vaccine return.
• Nurse: Enter the signature of the Nurse.
Contact Name Signature and Date: Enter the date and signature of person completing this report.
Mississippi State Department of Health
Revised 02-12-16
Form 131