COVID-19 Vaccine Transfer Request

All enrolled COVID-19 vaccine providers are required to upload data logger reports when submitting a transfer request.

Doses CANNOT be moved prior to approval from the Immunization Program.

Please allow (1) business day for approval.

Date you plan to transfer vaccines * +

Date of Request * +

Does the sending clinic have a redistribution agreement on file? *

Yes

No

The sending clinic is required to have a CDC redistribution agreement on file before the transfer can be approved.

If you need to submit a redistribution agreement, please go here to download the agreement. Have the CMO and CEO sign and return the completed form to cdphe_covidvax@state.co.us

Lack of redistribution agreement on file will delay approval of transfers.

Upload the most recent 5 days of data logger recordings for each unit(s) vaccines being transferred are stored in (NOT paper temperature logs or excel spreadsheets). *

Name of Clinic Requesting Transfer? *

Contact Name *

Contact Email *

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

YES

NO

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

Please list vaccine that you wish to transfer.
If you are transferring more inventory than fits in the columns below, please contact the COVID-19 vaccine program at cdphe_covidvax@state.co.us with the additional vaccine information.
DO NOT FILL THIS FORM OUT MORE THAN ONCE FOR THE SAME TRANSFER.

	Vaccine Brand	Lot Number	Expiration Date	Number of Doses
1	Vaccine Brand	Lot Number	Expiration Date	Number of Doses
2	Vaccine Brand	Lot Number	Expiration Date	Number of Doses
3	Vaccine Brand	Lot Number	Expiration Date	Number of Doses
4	Vaccine Brand	Lot Number	Expiration Date	Number of Doses
5	Vaccine Brand	Lot Number	Expiration Date	Number of Doses

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 Program

The Immunization Program will review this information and respond within one business day to the email provided in this form. If you have any questions about this form, please contact the COVID-19 vaccine program at cdphe_covidvax@state.co.us

Thank you.