COVID-19 Wastage and Temperature Excursion Reporting Form

Please provide a detailed description of what happened? • Which staff members were involved? • Approximately how much vaccine was involved? • What prevented this vaccine from being administered prior to expiration? • Include any other information you feel might be relevant to understanding the event.

• General description (i.e., what happened?) • Estimated length of time between event and last documented reading of storage temperature in acceptable range. • Prior to this event, have there been any storage problems with this unit and/or with the affected vaccine? • Include any other information you feel might be relevant to understanding the event.

• When were the affected vaccines placed in proper storage conditions? • Who was contacted regarding the incident? (For example, supervisor, Immunization Program, manufacturer—list all.) • IMPORTANT: What did you do to prevent a similar problem from occurring in the future?

• What happened to the vaccine? • Was it able to be used? If not, was it returned to the distributor?