HomeMy WebLinkAboutAdult Vaccine Program (2)Kittitas County
Review Form
Grants & Contract Agreement
Today's Date
02/27/2019
Fund/Department
116 -Public Health
Contract/Grant Information
Contract /Grant Agency: Adult Vaccine Program (AVP
Period Begin Date: 01/01/2019
Total Grant/Contract Amount:
Agenda Date
ASC A� 1, 4
r
Period End Date: 12/31/2020
Grant/Contract Number:
Contract/Grant Summary:
The Adult Vaccine Program is established for participating providers in the AVP to provide free vaccine
to those adults 19 and over that do not have insurance. The agreement outlines eligibility and scope of
work for the health department.
Recommendation for Board of Health and Board of Health Review on
Department Head Signature: Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office Date
Signature of Auditor's Office
Signature of Board of Health member
Financial Information
Date
Date
Total Amount $
State Funds $
Federal Funds $
Percentage County Funds
Matching Funds $
CFDA#
In -Kind $
Explain
Grant/Contract Review Page 1
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring — reporting requirements
Future impacts or liability to Kittitas County:
BudKet Information
Budget Amendment Needed? Yes
E]New Division Created?
Revenue Code
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub -Contract Approved Date:
attach budget form NO ❑ Why not
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes ❑ No ❑
County Departments Impacted
Submitted
Signature:
Department:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer I Date
Grant/Contract Review Page 2
Auditor
Facilities Maintenance
Information Services
Human Resource
Prosecutor
Treasurer
Submitted
Signature:
Department:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer I Date
Grant/Contract Review Page 2
Adult Vaccine Program IR-ml7
Office of Immunization and Child Profile
AVP Provider Agreement 2019
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INSTRUCTIONS
Providers participating in the Adult Vaccine Program (AVP) are required to enroll in the program annually.
Complete and send in this enrollment form via email(WAChildhoodVaccineg@dyh.wa.goy) or fax (Attn:
Adult Vaccine Program at 360.236.3811). For more program information, please review the AVP User
Manual.
STEP 1: Provide facility information, vaccine delivery information, and certify.
FACILITY INFORMATION
Facility Name: yts ,4r,4Pub11C Qeaht' a.e ..f.
PIN: 1&3 00®
Address: 5b% N gnun► ! �e (02
City: El e175 u State:
zip: gdg)7�
VACCINE DELIVERY ADDRESS
Shipping Address:(73 41 e,niemf S -k /a2
City: �� .?Y) W PAzip: �j �2lo
Telephone: 50 °1- 9(v 2 r ASIS Fax:,60q - q.33 - 5,2`6
Primary Contact Name: --ri rn Ro Backup Contact Name/I: L12 �%j)i�,kr
Email: -Lif'►').>Y� 1 eLo, lei � 0S, W, -4-V$ Email: l 2•i.U�1Vt �,.Co.%i' �AS, ivGr,✓5
VACCINE DELIVERY TIMES (Specify all days and hours your facility is available to receive vaccine. Providers are required
to be available for vaccine deliveries a minimum of four consecutive hours, two days a week, excluding Mondays).
MondayTuesday Wednesday Thursday N Friday
9 oa AM cl b° AM I °a AM to AM �% °0 AM
to to to to to
I f
7 90 PM 'f 00 PM aa PM 30PM 06PM
CERTIFICATION
Your participation in the 2019 Adult Vaccine Program (AVP) is appreciated. The Washington State
Department of Health (DOH) purchases adult vaccine to protect adults who could otherwise not afford to be
vaccinated. Increasing access to vaccines protects communities against vaccine preventable diseases. This
Provider Agreement specifies the conditions of participation in the AVP in Washington State. The agreement
must be signed and submitted to the Office of Immunization and Child Profile prior to receipt of vaccine.
y I certify that the above delivery address, dates and times to receive vaccine shipments are correct. I agree
to notify DOH immediately if any of my information changes.
�I understand and accept the conditions of this agreement and agree to comply with these requirements
on behalf of myself and all the practitioners associated with this facility. I agree to inform all providers in the
facility of their obligations under the agreement. DOH may terminate this agreement at any time for failure
to comply with these requirements. I may terminate this agreement at any time for personal reasons.
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 1 of 3
Adult Vaccine ProgramImmm
STEP 2: Agree to, and maintain compliance with, the following program policies.
Provider
+ A. Renew Provider Agreement yearly and update Agreement if there are any changes.
Agreement
B. Notify the program immediately regarding changes to address or delivery information.
C. Identify designated primary and secondary staff members to perform the
responsibilities of vaccine coordinator: ordering, receipt of vaccine, storage and
handling, and temperature monitoring.
Program
A. Ensure AVP vaccine is used for adults 19+ years of age, who are uninsured or
Eligibility
underinsured.
B. Fulfill all requirements for vaccine ordering and accountability, operate in a manner that
avoids fraud and abuse, and administer vaccine according to the recommendations of
the Advisory Committee of Immunization Practices (ACIP).
A. Have appropriate, approved storage unit(s) to store vaccine while maintaining proper
Storage &
Handling
storage conditions (dorm -style storage units are not allowed).
B. Have a primary and back-up thermometer with current certificates of calibration in
accordance with National Institute of Standards and Technology (NIST) or the American
Society for Testing and Materials (ASTM) standards for each unit that stores vaccine.
C. Ensure thermometers are calibrated and meet the requirements of the program.
D. New unit temperatures should be monitored for three to five (3-5) days prior to receipt
of vaccine to ensure temperature stability.
E. To monitor and ensure vaccine viability:
a. Check temperatures manually twice a day, at least three (3) times a week. Confirm
refrigerator temperatures are between 36"F and 46*F (2"C and 8°C). Confirm
freezer temperatures are between -58°F and 5°F (-50'C and -15°C)
b. Check the Minimum and Maximum temperatures once a day
c. Check thermometer data weekly to confirm temperatures are in range.
F. Ensure vaccines in all storage units are properly labeled.
G. Maintain accurate and complete temperature logs. Store completed logs for three (3)
years. Be able to submit logs for units storing AVP vaccine upon request.
H. Have a written emergency back-up plan and use it in the event of power outage or
equipment failure. Notify DOH within 24 hours of vaccine incidents and complete a
written report including the reasons for the vaccine loss and measures taken to correct
the cause of the loss and to prevent reoccurrence.
I. Have the capacity to store vaccine in addition to existing refrigerator/freezer stable
pharmaceuticals (e.g. other childhood/adult vaccines, seasonal flu vaccines, etc.).
J. Store and handle vaccine in accordance with the package insert and follow storage and
handling best practices.
K. Guarantee your facility will not function as a depot for AVP vaccine.
Accountability A. Ensure that staff administering and handling vaccine are properly trained and will
receive ongoing education and training on best practices in vaccine storage and
handling, and current immunization recommendations.
B. Notify the AVP of all vaccine that will expire three (3) months before expiration.
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 2 of 3
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