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Home My WebLink AboutAdult Vaccine Program (3)Adult Vaccine Progra* lnUn úTa;mOffice of lmmunization and Child Profile AVP Provider Agreement 2Ot9 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 (WAChildhoodVaccines@doh.wa.gov) 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 FACITITY INFORMATION Facility Name: i1,;,1á c.llh PIN: lü3 ooa Address:Sol V l,,lqnun, S+e ioL City:Elt(hsbura State: lil fr zip: q#12þ VACCINË DELIVERY ADDRESS ShippingAddress: Epl Ål Alnt,nr, S.it tDL €ity Elt ¿"tL*ä pù zip: qSqLb Telephone: 50q - qbf-l€tl Fax: 60e. qß- Bl'lt, Primary Contact Name: .1,- Rr+h Emait: *înrrv*h Q, ¿o " L¡Il,¿rs, wtr , vs Backup Contact Narne: L¡z lrtlh¡Jøh.Email: l¡z.w\.,iloL* e* ^ L;li-,¿ut, þ¡ø, ut¡ VACCINE DEUVERY flMES (Specifo all days and hours your facility is available to receive vaccine. Providers are required to be available for vacclne deliveries a minimum of four consecutlve hours, two days a weeÇ excluding Mondays). [Jtrrtonday ffi ruesday lX[wednesday ffithursday ffi rrioay I u' Rn¡ to lou pvr 700 to . t90.l AM PM ?0" au 4 to aO PM c/* *w 4 to Þ0 PM Qol e¡vt 4 to 0ô PM CERTIFICAT¡ON Your participation in the 2019 Adult Vaccine Program (AVP) is appreciated. The Washington State Department of Health (DOH) purchases adult vaccíne to protect adults who could otherwíse not afford to be vacc¡nated. lncreasing access to vaccines protects communities against vaccine preventable diseases. This Provider Agreement specifies the conditions of participation ín the AVP in Washington State. The agreement must be signed and submitted to the Office of lmmunization and Chíld Profile prior to receipt of vaccine. [l I certífy that the above delivery address, dates and times to receive vaccíne shipments are correct. I agree to notify DOH immediately if any of my information changes. Kt 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 thís 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 l'lDD/TW call 7ttl. DOH 348-637. January 2019. Page 1 of 3 Adult Vacci ne Program I nUn STEP 2: Agree to, and maintain compliance wíth, the following program policies. Provider Agreement A. Renew Provider Agreement yearly and update Agreement if there are any changes. B. Notify the program immediately regarding changes to address or delívery information C. ldentify desÍgnated primary and secondary staff members to perform the responsibilitíes of vaccine coordinator: ordering, receipt of vaccine, storage and handlÍng, and temperature monitorÍng. Program Eligibility A. Ensure AVP vaccine is used for adults 19+ years of age, who are uninsured or underinsured. B. Fulfill all requirements for vaccine ordering and accountabilÍty, operate ín a manner that avoids fraud and abuse, and administer vaccine according to the recommendations of the Advisory Committee of lmmunization Practices (ACIP). Storage & Handling A. Have appropriate, approved storage unit(s) to store vaccine while maintaining proper 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 lnstitute 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 stabil¡ty. 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 ternperatures 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 ín the event of power outage or equípment failure. Notify DOH within 24 hours of vaccíne incidents and complete a wrítten report including the reasons for the vaccine loss and measures taken to correct the cause of the loss and to prevent reoccurrence. l. Have the capacity to store vaccine in addition to existing refrigerator/freezer stable pharmaceuticals (e.g. other childhood/adult vaccínes, 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 handlíng 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 submít a request, please call 1-800-525-0127 (TÐD/TW call77tl. DOH 348-637. January 2019. Page 2 of 3 Adult Vaccine Program lÌtME C. Utílize the Vaccine Adverse Event Reportíng System (VAERS) to report any vaccine related adverse event (1-800-822-7967, https://vaers.hhs.eov/esub/index). D. Provide the most current Vaccine lnformation Statement (VlS) 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 ad ministered q ua rterly or month ly. G. Ensure ALI vaccine received from the AVP are accounted for at all times. Vaccine Loss & Transfers A. Complete and submit vaccine loss forms for all expired or spoiled vaccine. 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 Policies A. W¡ll not charge patients for vaccine or sell vaccine. B. Will not refuse to adrninister vaccine to patients who cannot afford an administration fee. May charge patients who can pay an administration fee up to 523.44. C. ls 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 narne, manufacturer, lot number, VIS publication date, date was given, and name and title of the immunization prov[der for each individual vaccinated. Keep the record for a minimum of three (31years 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. Program Coordinator Full Name f,nn %fit e ñ Med f N Program Coordinator Title ?uB¿-tc .il t*""*u p5É Medical Di Signature: ¿ /)*ñ Progra nator 4 'þ,61D \JbDt¡DãA-ì v For people with disabilities, this document is available upon request in other formats. To submit a request, please call 1-800-525-0127 lfDDlTTy call 711). DOH 348-637. January 2019. Page 3 of 3 Kittitas County Review Form Grants & Contract Agreement Contract/G rant I nformation Recommendation for Board of Health and Board of Health Review on Financial lnformation e4Õu7s Today's Date 02/27/2OL9 Agenda Date 3l tqltq Fund/Department L16-Public Health Contract /Grant Agency: Adult Vaccine Program (AVP) Period Begin Date: 0L/0L/z}tg Period End Date: 1213t/2O2O Total G rant/Contract Amou nt: Grant/Contract Number Contract/G ra nt 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. Department Head Sign Administrator o^r", Z/Zg// j Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: o Signatu s Date Sign itor's Office Date Signature of Board of Health member Date TotalAmount S State Funds 5 Federal Funds S Percentage County Funds Matching Funds S CFDA# ln-Kind S Expla¡n Grant/Contract Review Page 1- ls Equipment being purchased?Who owns equipment? New Personnel being hired?Contact HR hiring - reporting requirements Future impacts or liability to Kittitas County: B lnformation Pass Through Informat¡on Agency to Pass Through Amount to Pass Through s Sub-Contract Approved Date: Prosecutor Review Budget Amendment Needed?No n Why not New Division Created? Yes I attach budgetform Revenue Code Has the Prosecutor rev¡ewed this agreement?Yes LJ No l_l Cou De rtments lm acted Submitted Auditor Faci lities Maintenance lnformation Services Human Resource TreasurerProsecutor Signature:Date: Department: Assignment of Tracking lnformation Auditor's Office Human Resource Prosecutor's Office Who Signed the grant application Reviewer Date Grant/Contract Review Page 2