Organisation name ______Contact Name ______
Phone ______Fax ______Email ______
Incident date ______Incident Type Fridge Failure Power Outage Transport issue
User Error Vaccine Expiry Other ______
Incident description ______
______
For cold chain breach incidents please do not discard any government-funded vaccines. Isolate & keep affected vaccines refrigerated between 2˚C to 8˚C and clearly label ‘do not use’. Complete this form, attach the data logger numerical read out, and fax to your public/population health unit (PHU) using the contact details below. The regional immunisation coordinator (RIC) will contact you to advise, including which vaccines to retain or discard.
Record Max/Min temperature for this breach ______Time outside 2 to 8°C ______
Have any vaccines been administered since breach occurred? Yes No
Have any vaccines been affected by a previous cold chain breach? Yes No (if yes, give breach date and details below)
Previous breach date ______Previous breach details ______
______
Record only government-funded vaccine doses in the table below (write in other government-funded vaccines at bottom of table)
Immunisation provider record doses / RIC to complete / Immunisation provider record doses / RIC to complete
Vaccines / No. doses / Retain / Discard / Vaccines / No. doses / Retain / Discard
Adacel / Neisvac-C
Bexsero / Pneumovax
Boostrix / Prevenar 13
Engerix / Priorix
Fluarix Tetra / Priorix Tetra
FluQuadri Junior / ProQuad
Gardasil / Quadracel
Havrix / Rabipur / rabies vaccine
HBVax-II Paed / RotaTeq
Hiberix / Tripacel
Infanrix / Twinrix
Infanrix Hexa / Vaqta
Imogam / Kamrab / Varilrix
Ipol / Varivax
Menitorix / Zostavax
Menveo / Other______
MMR-II / Other______
Please indicate your PHU below and send this report by using the contact details listed. The RIC will contact you.
(PHU’s are identified by postcode at http://www.healthywa.wa.gov.au/publichealthunits)
Tick PHU / Public/Population Health Unit / Fax no. for Incidents excluding Expiry / Fax no. for Vaccine Expiry / Phone no.
Goldfields / 9080 8201 / 9080 8201 / 9080 8200
Great Southern / 9892 2503 / 9892 2503 / 9842 7500
Kimberley / 9194 1631 / 9194 1631 / 9194 1630
Midwest / 9956 1991 / 9956 1991 / 9956 1980
Pilbara / 9174 1088 / 9174 1088 / 9174 1660
South West / 9781 2382 / 9781 2382 / 9781 2355
Wheatbelt / 9622 5752 / 9622 5752 / 9622 4320
Metro CDC / 9222 8599 / 9388 4877 expiry only / 9222 8588
PHU RIC Use Only PHU RIC Name ______RIC Phone No. ______
Form actioned by RIC and returned to provider with advice, including which vaccines to retain or discard (as applicable)
Provider is authorised to order replacement vaccines (cold chain incident rectified) OR
Provider is not authorised to order replacement vaccines and CDCD has been notified
Completed form sent to CDCD by PHU RIC (fax 9388 4877 or scan via email to )
Cold Chain and Wastage Form Jan 2017 http://ww2.health.wa.gov.au/Corporate/Articles/A_E/Cold-chain-management