COVID-19 Provider Redistribution Plan

COVID-19 Vaccine Redistribution(2)

COVID-19 Provider Redistribution Plan
Redistributing facility Information:
Company Name*
VTrckS ID:
VIIS Org Code:
Address:*
City:*
Zip-Code:*
Storage and Temperature Monitoring:
(Must comply with ALL CDC storage and handling protocols.)
Describe permanent storage unit information:
Describe Temperature monitoring practices:
Re-distribution training Documentation:
(CDC requires all personnel packing vaccines must have proper training.)
Describe the training provided to recipient sites and how it is documented:
Describe vaccine redistribution process, which complies with CDC transport recommendations:
Describe ancillary supplies redistribution process:
Reminder:

All Inventory shall be reported in Vaccine Finder. COVID-19 Vaccine recovery process details are still being finalized and will be communicated when available. Disposition of the COVID-19 vaccine must be in accordance with forthcoming guidelines.

Division of Immunization (DOI) COVID-19 Redistribution Policy
List of recipient sites:
How many sites will you be distributing to:*
There is a max of 25 sites per form.
Site 1:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 2:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 3:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 4:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 5:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 6:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 7:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 8:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 9:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 10:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 11
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 12:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 13:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 14:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 15:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 16:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 17:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 18:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 19:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 20:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 21:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 22:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 23:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 24:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
Site 25:
Facility Name:
What address are you redistributing the Vaccine(s)/Kit(s):
Receiving Site VTrckS ID:
Doses administered are documented using:
Doses administered data are shared with VIIS via:
Enter your "OTHER" answer here:
Please describe temperature monitoring, storage capacity?
One more field...
Email address for the person completing this form:*
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COVID-19 Vaccine Redistribution(2)

COVID-19 Provider Redistribution Plan

Redistributing facility Information:

Storage and Temperature Monitoring:

Re-distribution training Documentation:

Reminder:

Division of Immunization (DOI) COVID-19 Redistribution Policy

List of recipient sites:

Site 1:

Site 2:

Site 3:

Site 4:

Site 5:

Site 6:

Site 7:

Site 8:

Site 9:

Site 10:

Site 11

Site 12:

Site 13:

Site 14:

Site 15:

Site 16:

Site 17:

Site 18:

Site 19:

Site 20:

Site 21:

Site 22:

Site 23:

Site 24:

Site 25:

One more field...