139x Filetype PDF File size 0.28 MB Source: coronavirus.wh.org.au
CONFIDENTIAL This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients of this document shall not use or disclose the information contained in this document for any purpose other than for the authorised activities under COVID-19 vaccine national roll-out strategy. COVID-19 Vaccine Roll-out Australian Government COVID-19 Vaccine Stock Management Form This ‘Vaccine Stock Management Form’ should be completed at the end of each day during the period that COVID-19 vaccine is held at the location to which the vaccine is delivered (Site) and then sent to COVID19VaccineStock@health.gov.au by no later than 9pm each day (local time at the Site). It is critical that cold-chain storage and handling requirements for the vaccine are maintained at all times and are not breached during the stocktake process. This means that: o o • the AZ vaccine must be maintained at 2 C to 8 C • the Pfizer vaccine must be maintained at: o o • -60 C to -90 C (if the Pfizer vaccine is frozen); o o • 2 C to 8 C (if the Pfizer vaccine has been thawed). If the Site holds more than one type of COVID-19 vaccine, a separate form must be completed for each vaccine. Details Vaccine [Insert AZ vaccine or Pfizer vaccine] Site ID (if applicable): Name of Site: Address of Site: Date of Vaccine Stock Management Form: Name of authorised contact person at Site: Contact details of authorised contract person at Site (Email address and phone number): Location(s) of administration of vaccines (insert “This Site only” or add the name and address of any other vaccine administration location(s)) 1 CONFIDENTIAL This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients of this document shall not use or disclose the information contained in this document for any purpose other than for the authorised activities under COVID-19 vaccine national roll-out strategy. STOCK SUMMARY Required Information # Vials # Doses Comments (Identify any issues) *Usable stock on hand at the start of the day *Note: do not include any stock held in quarantine due to issues identified at delivery or for any other reason. Number of doses and vials of vaccine administered to patients during the day Number of doses and vials transferred TO Details of location(s) TO which the vaccines other location(s) during the day were transferred: Number of doses and vials transferred Details of location(s) FROM which the FROM other location(s) during the day vaccines were transferred: Usable stock on hand at end of current day 2 CONFIDENTIAL This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients of this document shall not use or disclose the information contained in this document for any purpose other than for the authorised activities under COVID-19 vaccine national roll-out strategy. Summary of Wastage Please complete this section to provide Health with details of all wastage that may have occurred during the day. Where a potential wastage incident or an actual wastage incident (e.g. damaged vials, breach of cold chain requirements) involves 5 or more vials at one time, you must notify Health immediately by calling the Vaccine Operations Centre on 1800 318 208 and by emailing Health, and include a detailed Vaccine Wastage Report (the separate form) in your email, to COVID19VaccineWastage@health.gov.au. In addition, all wastage for the day must be reported using the table below. An explanation of the specific details as to how wastage occurred should be provided by completing the right-hand column. Summary of Wastage Yes/No # vials # doses Details of how wastage occurred and wasted wasted any other comments 1. Was there a wastage incident Yes/No during the day over the threshold (5 or more vials)? 2. If yes to Q1, did you report Yes/No the incident immediately to Health? 3. Was there wastage below the Yes/No threshold during the day? 4. What was the total volume of wastage during the day? 3 CONFIDENTIAL This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients of this document shall not use or disclose the information contained in this document for any purpose other than for the authorised activities under COVID-19 vaccine national roll-out strategy. Signature Completed by: _________________ Position: _________________ Signature: ___________________ Date: __________________ Checked by: _________________ Position: _________________ Signature: ___________________ Date: ___________________ Note: giving false or misleading information to the Commonwealth is a criminal offence. 4
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