IMM-39, Vaccine Return Voucher
|New Jersey Department of Health |VACCINE RETURN VOUCHER |
|Vaccines for Children (NJVFC) Program | |
|PO Box 369 | |
|Trenton, NJ 08625-0369 | |
|Phone: 609-826-4862 Fax: 609-826-4867 | |
* Report all wasted or non-viable vaccine to NJVFC Program;
complete multiple forms for more than one of the same vaccines.
|Site Name |PIN Number |Date |
| | | |
|Name of Contact Person |Telephone Number |Fax Number |
| |( ) |( ) |
|WASTED/EXPIRED VACCINE |
|* Codes: W-Wasted/Spoiled E-Expired T-Transfer |
|Vaccine Type |NDC Number |Lot Number |Expiration Date |Code* |Number |
| | | | | |of Doses |
|DtaP | | | | | |
|DtaP-HepB-IPV | | | | | |
|DtaP-Hib-IPV | | | | | |
|DtaP/IPV | | | | | |
|Tdap | | | | | |
|Td Adult | | | | | |
|Hib | | | | | |
|Hib Booster | | | | | |
|Pneumococcal Conj. PVC13 | | | | | |
|Pneumococcal Polysaccharide | | | | | |
|IPV | | | | | |
|MMR | | | | | |
|MMRV | | | | | |
|Hep B/Hib | | | | | |
|Hepatitis B (3 Dose) | | | | | |
|Hepatitis B (2 Dose) | | | | | |
|Hepatitis A | | | | | |
|Hepatitis A and B | | | | | |
|Human Papillomavirus (HPV) | | | | | |
|Rotavirus (3 Dose) | | | | | |
|Rotavirus (2 Dose) | | | | | |
|Varicella | | | | | |
|Meningococcal Conjugate | | | | | |
|Influenza | | | | | |
|Influenza, Live Intranasal | | | | | |
|Zoster | | | | | |
|Explain why vaccines are being returned (Mandatory): |
| |
|NJVFC MUST be called to obtain permission for vaccine transfer. |
|Transfer approved by: ______________________________ to PIN: ____________ |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- xfinity blast internet 39.99
- xfinity 39.99 deal
- xfinity 39.99 internet
- comcast 39 99
- apply for hud voucher online
- housing choice voucher open list
- xfinity blast internet 39 99
- 39 lincoln zephyr coupe
- housing choice voucher online application
- xfinity 39 99 internet deal
- xfinity 39 99 deal
- apply for section 8 voucher online