Vaccines for Children (VFC) Vaccine Transport Log

Instructions: Complete the vaccine transport log when transporting vaccines to another location and/or emergency alternate or backup receiving location or after an off-site clinic is complete. A calibrated, digital data logger must be used for monitoring and recording temperatures while transporting vaccines. Report out-of-range temperatures to the VFC Program.

When the transport log is submitted, VFC staff will create the transfer in CIIS for your clinic. Transfers will not be created in CIIS for off-site clinics.

Please contact the VFC Program at cdphe_vfc@state.co.us or 303-692-2650 if you have questions or need additional information.

Hit the SUBMIT button at the end of this form. After submitting the form, an email confirmation will be sent. Keep a copy of the VFC Transfer Request form for your records.

Date Clinic Transported Vaccine(s) * +

VFC PIN *

Name of Clinic Requesting Vaccine Transport *

Contact Name *

Direct Telephone Number *

Contact Email *

VFC PIN *

Name of Clinic Receiving Vaccine Transport *

What is the reason your clinic transported vaccines? *

List of Vaccines Transported

If you transported more than 10 vaccines to another clinic, download the Excel spreadsheet template below. Then upload it into the Vaccine Transport log.
List of Transported Vaccine(s) Template

	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
1	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
2	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
3	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
4	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
5	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
6	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
7	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
8	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
9	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported
10	Vaccine	Lot Number	Expiration Date	Beyond Use Date (BUD)	Fund Source (VFC/317/State)	# of Doses to Transported

Temperature Monitoring Information & Data Logger Upload

VFC-required temperatures during transport and for on-site vaccine storage:

Refrigerated 2°C to 8°C (36°F to 46°F)

Frozen (+5°F or below) or (–15°C or below)

*

	TEMPERATURE (°F or °C)	TIME (A.M./P.M)
The temperature of vaccines in the unit before the transfer	TEMPERATURE (°F or °C)	TIME (A.M./P.M)
The temperature of vaccines in the transport unit before departure	TEMPERATURE (°F or °C)	TIME (A.M./P.M)
The temperature of vaccines on arrival	TEMPERATURE (°F or °C)	TIME (A.M./P.M)
The temperature of the receiving storage unit	TEMPERATURE (°F or °C)	TIME (A.M./P.M)

Total time vaccines in transit (hour and minutes) *

Upload the Data Logger Report(s) during transport *

Additional Comments for the VFC Program