2018 VFC Provider Agreement - Laserfiche WebLink

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