COVID-19 Vaccine Transfer Request

The transfer must be approved before the doses can physically be moved to another location.

Please allow (1) business day for approval.

Date you plan to transfer vaccines * +

Date of Request * +

Name of Clinic Requesting Transfer: *

Contact Name *

Contact Email *

Do you want CDPHE to create the transfer in CIIS for your facility?
IF YOU WILL CREATE THE TRANSFER IN CIIS YOURSELF, PLEASE SELECT " NO" *

YES

NO

If you don't see a clinic listed in the drop down menu, you CANNOT transfer vaccine to them. This will be updated nightly as new sites are enrolled.

Name of Receiving Clinic (The receiving site must be enrolled as a COVID-19 vaccine provider) *

Please list vaccine that you wish to transfer.
DO NOT FILL THIS FORM OUT MORE THAN ONCE FOR THE SAME TRANSFER.

	Vaccine Brand	Lot Number	Expiration	Number of DOSES (not vials) you wish to transfer
1	Vaccine Brand	Lot Number	Expiration	Number of DOSES (not vials) you wish to transfer
2	Vaccine Brand	Lot Number	Expiration	Number of DOSES (not vials) you wish to transfer
3	Vaccine Brand	Lot Number	Expiration	Number of DOSES (not vials) you wish to transfer
4	Vaccine Brand	Lot Number	Expiration	Number of DOSES (not vials) you wish to transfer
5	Vaccine Brand	Lot Number	Expiration	Number of DOSES (not vials) you wish to transfer

Have any of the vaccines that you intend to transfer been exposed to temperatures outside of recommended storage requirements? *

Yes

No

If yes, please give the receiving clinic the manufacturer recommendations and lot number information.

Input your email address below to receive a copy of this form. *

Additional Comments for Immunization Branch

The Immunization Branch will review this information and respond within one business day to the email provided in this form.

Thank you.