VFC Vaccine Return and Wastage Form

For all temperature excursions, please confirm vaccine viability with vaccines manufacturers FIRST!!!

Date*
MM slash DD slash YYYY
VFC PIN*
Practice Name*
Phone number*
Fax Number*
Completed By:*
Email*
Instructions for Completion:
1. Immediately remove any wasted or expired/spoiled vaccine from the refrigerator or freezer. 2. Upon receipt, VFC will email a confirmation and the Vaccine Transaction Receipt to be enclosed in the package with the vaccine being returned to McKesson. DO NOT return wasted vaccine (opened and unused multi-dose vials, broken vials/syringe, etc.). Wasted vaccine should be disposed of according to facility protocol. 3. Upon receipt of the shipping label(s) from McKesson, via email, attach label to the container and give to UPS. Clearly label the outside of the shipping container "Non-viable Vaccine enclosed".
EXPIRED / SPOILED VACCINE ONLY
Vaccine in which the date listed on the vaccine container has elapsed. Vaccine that is no longer viable due to lack of proper storage. Click the + button to add additional vaccine.
Vaccine Manufacturer NDC Number Number of Doses Expiration Date
WASTAGE ONLY
Broken vial/syringe; Vaccine drawn up into syringe but not administered; Lost or unaccounted for vaccine; Non-vaccine product (e.g., diluent); Partially used multi-dose vial. Click the + button to add additional vaccine.
Vaccine Manufacturer NDC Number Number of Doses Expiration Date
Reason for vaccine return (all types i.e for expired/spoiled or wastage).*
Type reason here.

Instructions for Completion:

Vaccine	Manufacturer	NDC Number	Number of Doses	Expiration Date

Vaccine	Manufacturer	NDC Number	Number of Doses	Expiration Date