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Adult Vaccine Program lR No C. Utilize the Vaccine Adverse Event Reporting System (VAERS) to report any vaccine related adverse event (1-800-822-7967, https://yaers.hhs.gov/esub/index). D. Provide the most current Vaccine Information Statement (VIS) to each patient receiving vaccine, and answer questions about the benefits and risks of vaccination. E. Comply with ACIP recommendations for use of vaccines and their administration techniques, including observation of priority groups if any. Priority groups include, but are not limited to, pregnant women, immunocompromised persons, etc. F. Maintain and report complete, accurate vaccine inventory records based on reporting requirements. Report inventory/doses administered quarterly or monthly. G. Ensure ALL vaccine received from the AVP are accounted for at all times. Vaccine Loss A. Complete and submit vaccine loss forms for all expired or spoiled vaccine. & Transfers B. Obtain approval from the program before making any transfers. C. Transfer vaccines only to actively enrolled AVP providers, following transfer guidelines. D. Ensure vaccine temperatures are monitored during transport. E. Upon completion of the transfer turn in the completed transfer form. Additional A. Will not charge patients for vaccine or sell vaccine. Policies B. Will not refuse to administer vaccine to patients who cannot afford an administration fee. May charge patients who can pay an administration fee up to $23.44. C. Is strongly encouraged to provide an immunization record card to the patient and provide information if a VAERS report is submitted. D. Record in patients' medical record date of administration, site of administration, vaccine name, manufacturer, lot number, VIS publication date, date was given, and name and title of the immunization provider for each individual vaccinated. Keep the record for a minimum of three (3) years following vaccination. Step 3: This agreement must be signed by the organization's Medical Director, authorized to bind the organization to the terms of the agreement. The Medical Director's name and Washington State medical license number must be included. Medical Director Full Name: Medical Director License Number: Medical Director Signature: Date: Program Coordinator Full Name: Program Coordinator Title: Program Coordinator Signature: Date: For people with disabilities, this document is available upon request in other formats. To submit a request, please call 1-800-525-0127 (TDD/TTY call 711). DOH 348-637. January 2019. Page 3 of 3