Download Cold Chain Break Report - Alberta Health Services

Cold Chain Break Report
Part A
Date Break Occurred (yyyy-Mon-dd) Date of Report (yyyy-Mon-dd)
Reporter Name
Telephone Number
Reporter Email Address
Fax Number
Location of Break (City/Town, Facility Name, Fridge # if applicable)
AVI PIN #
Facility Type
Pharmacy
Public Health
LTC
Acute Care
Private Agency (e.g. WeCare, Shell)
Other (specify)
Type of Cold Chain Break
Temperature excursion (less than 2.00C and greater than 8.00C)
Light Exposure
Physician Office
AHS Zone
AHS Zone Vaccine Contact
South
Edmonton
Telephone Number
Calgary
North
Central
Fax Number
Description of Break
Are products now quarantined, labeled “do not use”, and back in cold chain?
Yes
No (If no, explain)
Last temperature recorded before the break
0C
date (yyyy-Mon-dd)
time (hh:mm)
Temperature at time break identified
0C
date (yyyy-Mon-dd)
time (hh:mm)
date (yyyy-Mon-dd)
time (hh:mm)
Vaccine returned to storage between
2.00C
and
8.00C
0C
Maximum temperature recorded during interval
Time out of cold chain (if different than above - provide evidence in description or attachments, e.g. chart tracing)
Refrigerator Type
Lab Fridge
Other (specify)
Thermometer/Monitor Type (not brand name)
Digital Min/Max
Chart Recorder
Warm/Cold Mark
No Monitor
Other (specify)
Domestic Fridge
Cause of Cold Chain Break
Human Error
Thermometer Malfunction
Power Outage
Refrigerator Malfunction
Other (specify)
0C
Minimum temperature recorded during interval
hours
TT4
Products involved in previous breaks
No
Yes date (yyyy-Mon-dd)
location
date (yyyy-Mon-dd)
location
If products have been involved in a previous break(s),
save a copy of Part A and report those doses using a
separate Cold Chain Break Report form.
If transportation involved, indicate type (e.g. car, courier)
Transportation between
Provincial Vaccine Depot – Alberta Health Services
Alberta Health Services – Public Health
Alberta Health Services – Community Providers
Have any affected products been administered to clients?
Yes – clearly indicate these products
20322 (Rev2016-09)
No
Fax or Email to Zone Contact
Page 1 of 4
Cold Chain Break Report
Part B
Date Break Occurred (yyyy-Mon-dd)
Alberta Health publicly-funded
vaccine ONLY
Single Dose Preparations
Location of Break
Lot #
Count
If more than 2 lot numbers
use separate page(s)
Doses
Lot #
Count
If more than 2 lot numbers
use separate page(s)
CDC Use Only
Viable
Not Viable
Doses
dTap - ADACEL
dTap - BOOSTRIX
dTap-IPV - BOOSTRIX-POLIO
DTaP-IPV - INFANRIX-IPV
DTaP-IPV - QUADRACEL
DTaP-IPV-Hib - INFANRIX-IPV+Hib
DTaP-IPV-Hib - PEDIACEL
DTaP-IPV-Hib-HB – INFANRIX HEXA
Hepatitis A Adult - HAVRIX 1440
Hepatitis A Pediatric - HAVRIX 720
Hepatitis A Adult - VAQTA
Hepatitis A Pediatric - VAQTA
Hepatitis A & B Adult - TWINRIX
Hepatitis A & B Pediatric - TWINRIX Jr
Hepatitis B Adult - ENGERIX
Hepatitis B Adult - RECOMBIVAX
Hepatitis B Dialysis - RECOMBIVAX
Hepatitis B Pediatric - ENGERIX
Hepatitis B Pediatric - RECOMBIVAX
Hib - ACT-HIB
Hib - HIBERIX
HPV-9 - GARDASIL 9
IG - GAMASTAN
Influenza: QLAIV - FLUMIST
Influenza: QIV - FLULAVAL
Influenza: QIV - FLUZONE
Influenza: Adjuvanted - FLUAD
MMR - MMR II
MMR - PRIORIX
MMR-Var - PRIORIX-TETRA
MMR-Var - PROQUAD
Meningococcal B - BEXSERO
MenconC - MENJUGATE
MenconC - NEISVAC-C
MenC-ACYW - MENACTRA
MenC-ACYW - MENVEO
20322 (Rev2016-09)
Fax or Email to Zone Contact
Page 2 of 4
Cold Chain Break Report
Part B - continued
Date Break Occurred (yyyy-Mon-dd)
Alberta Health publicly-funded
vaccine ONLY
Single Dose Preparations
Location of Break
Lot #
Count
If more than 2 lot numbers
use separate page(s)
Lot #
Count
Doses
Doses
Sealed
Vials
Sealed
Vials
If more than 2 lot numbers
use separate page(s)
CDC Use Only
Viable
Not Viable
PNEU-C13 - PREVNAR 13
PNEUMO-P - PNEUMOVAX-23
Polio - IMOVAX POLIO
Rabies - IMOVAX RABIES
Rabies - RABAVERT
RIG - IMOGAM RABIES
Rotavirus - ROTARIX
Td - TD ADSORBED
Td-IPV - TD POLIO
TIG - HYPERTET
Typhoid - TYPHIM VI
Varicella - VARILRIX
Varicella - VARIVAX III
Other:
Multi-dose Preparations
FLUVIRAL - Influenza
# of open vials
FLUZONE - Influenza
# of open vials
Tuberculin - TUBERSOL (5TU)
# of open vials
Additional Comments
20322 (Rev2016-09)
Fax or Email to Zone Contact
Page 3 of 4
Cold Chain Break Report
Part C – AHS Facilities Only
Date Break Occurred (yyyy-Mon-dd)
Location of Break
Lot #
Purchased Product
Count
Single Dose Preparations
If more than 2 lot numbers
use separate page(s)
Lot #
Count
Doses
Doses
Sealed
Vials
Sealed
Vials
If more than 2 lot numbers
use separate page(s)
CDC Use Only
Viable
Not Viable
dTap - ADACEL
dTap - BOOSTRIX
dTap-IPV - ADACEL-POLIO
dTap-IPV - BOOSTRIX-POLIO
Hepatitis A Adult - AVAXIM
Hepatitis A Pediatric - AVAXIM
Hepatitis A Adult - HAVRIX 1440
Hepatitis A Pediatric - HAVRIX 720
Hepatitis A Adult - VAQTA
Hepatitis A Pediatric - VAQTA
Hepatitis A & B Adult - TWINRIX
Hepatitis A & B Pediatric - TWINRIX Jr
Hepatitis A and Typhoid - VIVAXIM
Hepatitis B Adult - ENGERIX
Hepatitis B Pediatric - ENGERIX
Hepatitis B Adult - RECOMBIVAX
Hepatitis B Pediatric - RECOMBIVAX
Herpes Zoster - ZOSTAVAX
HPV-9 - GARDASIL 9
Japanese Encephalitis - IXIARO
MMR - PRIORIX
MMR - MMR II
MenC-ACYW - MENACTRA
MenC-ACYW - MENVEO
Meningococcal B - BEXSERO
PNEU-C13 - PREVNAR 13
Polio - IMOVAX POLIO
Rabies - IMOVAX RABIES
Rabies - RABAVERT
Td-IPV - Td POLIO
Typhoid - TYPHERIX
Typhoid - TYPHIM VI
Varicella - VARILRIX
Varicella - VARIVAX III
Yellow Fever - YF-VAX
Multi-dose Preparations
Tuberculin - TUBERSOL (5TU)
# of open vials
20322 (Rev2016-09)
Fax or Email to Zone Contact
Page 4 of 4