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Adult Vaccine Program lÌtME <br />C. Utílize the Vaccine Adverse Event Reportíng System (VAERS) to report any vaccine <br />related adverse event (1-800-822-7967, https://vaers.hhs.eov/esub/index). <br />D. Provide the most current Vaccine lnformation Statement (VlS) to each patient receiving <br />vaccine, and answer questions about the benefits and risks of vaccination. <br />E. Comply with ACIP recommendations for use of vaccines and their administration <br />techniques, including observation of priority groups if any. Priority groups include, but <br />are not limited to, pregnant women, immunocompromised persons, etc. <br />F. Maintain and report complete, accurate vaccine inventory records based on reporting <br />requirements. Report inventory/doses ad ministered q ua rterly or month ly. <br />G. Ensure ALI vaccine received from the AVP are accounted for at all times. <br />Vaccine Loss <br />& Transfers <br />A. Complete and submit vaccine loss forms for all expired or spoiled vaccine. <br />B. Obtain approval from the program before making any transfers. <br />C. Transfer vaccines only to actively enrolled AVP providers, following transfer guidelines. <br />D. Ensure vaccine temperatures are monitored during transport. <br />E. Upon completion of the transfer turn in the completed transfer form. <br />Additional <br />Policies <br />A. W¡ll not charge patients for vaccine or sell vaccine. <br />B. Will not refuse to adrninister vaccine to patients who cannot afford an administration <br />fee. May charge patients who can pay an administration fee up to 523.44. <br />C. ls strongly encouraged to provide an immunization record card to the patient and <br />provide information if a VAERS report is submitted. <br />D. Record in patients' medical record date of administration, site of administration, vaccine <br />narne, manufacturer, lot number, VIS publication date, date was given, and name and <br />title of the immunization prov[der for each individual vaccinated. Keep the record for a <br />minimum of three (31years following vaccination. <br />Step 3: This agreement must be signed by the organization's Medical Director, authorized to bind the <br />organization to the terms of the agreement. The Medical Director's name and Washington State medical <br />license number must be included. <br />Program Coordinator Full Name <br />f,nn %fit e ñ <br />Med f N <br />Program Coordinator Title <br />?uB¿-tc .il t*""*u p5É <br />Medical Di Signature: ¿ <br />/)*ñ <br />Progra nator <br />4 'þ,61D <br />\JbDt¡DãA-ì v <br />For people with disabilities, this document is available upon request in other formats. <br />To submit a request, please call 1-800-525-0127 lfDDlTTy call 711). DOH 348-637. January 2019. <br />Page 3 of 3