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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Why are you requesting to transfer VFC vaccine? *
 
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. 
 VaccineLot NumberExpirationFunding Source (VFC/317)Number of doses you wish to transfer
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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). *
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? *
 
What type of insulating materials will you be using?
*NO ICE OR GEL PACKS PERMITTED
 *
 
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). *
The VFC program will review this information and respond within one business day to the email provided in this form.
Thank you.