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Colorado VFC & 317 Vaccine Transfer Request
NOTE: If you have expiring vaccine but have not arranged a provider to accept it, please contact the VFC Program instead of filling out this form
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Date of Request
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Name of Clinic Requesting Transfer:
*
PIN of Clinic Transferring Vaccines
*
Contact Name
*
Contact Email
*
Name of Receiving Clinic
*
PIN of Receiving Clinic:
*
Contact Name of Receiving Clinic:
*
Contact Email of Receiving Clinic:
*
Date you plan to transfer vaccines
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Why are you requesting to transfer VFC vaccine?
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Vaccine is expiring
Running low on vaccine in between orders
Storage unit maintenance/repair
Address Change
Planned Power outage
Temporary Clinic Closure
Other
Other
Please list vaccine that you wish to transfer.
If you are transferring more than 15 vaccines, please contact the VFC program at cdphe_vfc@state.co.us with the additional vaccines that do not fit on this form.
DO NOT FILL THIS FORM OUT MORE THAN ONCE FOR THE SAME TRANSFER.
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
1
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
2
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
3
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
4
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
5
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
6
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
7
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
8
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
9
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
10
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
11
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
12
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
13
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
14
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
15
Vaccine
Lot Number
Expiration
Funding Source (VFC/317)
Number of doses you wish to transfer
Have any of the vaccines that you intend to transfer been affected by a temperature excursion? (Please verify by looking over excursion documents and lot numbers).
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Yes
No
If yes, please give the receiving clinic the manufacturer recommendations and lot number information.
What type of unit do you plan to use to transport vaccine?
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Portable Storage Unit
Qualified Container & Pack Out (Vericor, Safe Acutemp)
Hard-sided food cooler
Styrofoam shipping container
Other
Other
What type of insulating materials will you be using?
*NO ICE OR GEL PACKS PERMITTED
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None, using portable fridge/freezer
Insulated panels
Conditioned water bottles
Frozen water bottles (for frozen vaccine only)
Other
Other
Do you have a back up data logger to transport these vaccines? (note, if you are transporting both frozen and refrigerated vaccines, you need two loggers).
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Yes
No
Input your email address below to receive a copy of this form.
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Additional Comments for the VFC Program
The VFC program will review this information and respond within one business day to the email provided in this form.
Thank you.