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_.............. .......... <br />......_.... _.._ . <br />Vaccine A. Ensure that all vaccine shipments are promptly received and stored immediately and report <br />Shipments any problems with vaccine shipments immediately to the LHJ. <br />B. Make sure all staff who receive mail at the provider location know how to handle shipments <br />of vaccine. <br />Vaccine Wastage <br />A. Implement written procedures for reporting and responding to losses resulting from vaccine <br />expiration, wastage, and compromised cold chain. <br />B. Notify the local health jurisdiction promptly (within 24 hours) of vaccine incidents where <br />vaccine has been exposed to temperatures above or below the recommended range for <br />vaccine storage. Follow state and LHJ guidance on how to document and report the incident. <br />C. Bag affected vaccine, mark it do not use, and store it at appropriate temperatures until <br />viability is confirmed by the manufacturer. <br />D. Create a written report including the reasons for the vaccine loss. Note the measures taken <br />to correct the cause of the loss and to prevent reoccurrence. This report must be submitted <br />to the LHJ. <br />E. If the vaccine is deemed non-viable, remove wasted/expired vaccine from storage containers <br />with viable vaccine to prevent inadvertent administration. Return all unopened spoiled or <br />expired publicly purchased vaccines following the state returns process. <br />F. Vaccine losses determined to be the result of negligent vaccine storage and handling <br />practices, or failure to comply with the storage and handling requirements in this agreement <br />may result in corrective action. Corrective action may include restitution for the value of all <br />federal- and state- supplied vaccine loss resulting from the incident. <br />Vaccine <br />A. Make immunization records available to the local health jurisdiction and the state <br />Accountability <br />Department of Health Immunization Program (if requested). <br />B. Participate in a site visit by the local health jurisdiction or state Department of Health, which <br />may include an immunization assessment (AFIX). <br />C. Provide data on the number, age and VFC status of children seen in the practice by <br />completing the annual data request for the provider profile. <br />D. Complete a provider satisfaction survey (if requested). <br />E. Complete the Private Provider's Report of Vaccine Usage form provided by the local health <br />jurisdiction, which includes: the doses of vaccine administered by vaccine type and age group <br />of each patient; doses of vaccine wasted, lost or expired; inventory of vaccine by vaccine <br />type and number of doses. <br />Vaccine Security A. Post "Do Not Disconnect" signs at both the electrical outlet where your storage unit is <br />and Equipment plugged in and the circuit breaker to prevent storage units losing power. <br />Maintenance <br />By initialing this form, I agree to the Washington State -specific requirements listed above and understand I am <br />accountable (and each listed provider is individually accountable) for compliance with these requirements. <br />Medical Director or Equivalent Name (print): Initials: Date: <br />