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|[pic] |Ministry of Health |Ontario Government |Non-Reusable Vaccine |

| |and Long-Term Care |Pharmaceutical and |(spoiled or expired) |

| | |Medical Supply Service |Return Record |

| | |99 Adesso Drive |Toronto Clients |

| | |Concord ON L4K 3C7 | |

| | |Tel. (416) 327-0837 | |

| | |Fax (416) 327-0818 | |

|Contact the Ontario Government Pharmaceutical and Medical Supply Service for a Return Authorization Number. |

|Attach completed form and/or non-reusable vaccine sticker to outside of package. |

|Give to OGPMSS driver when next order is delivered. |

|Client name |Client number |Return authorization no. |

|      |      |      |

|Returned by |Telephone no. |Date of return (yyyy-mm-dd) |

|      |      |      |

|Code name |Description |Lot no. |Cat. no. |No. of Pkg. |*Reason |

| | | | | |for return |

|ADACEL® |Tetanus and Diphtheria Toxoids Adsorbed combined with Component Pertussis Vaccine |      |6571-2203-0 |     |      |

| |(5 x 0.5 mL) | | | | |

|BID (Mantoux) |Tuberculin Purified Protein Derivative 5 TU (Mantoux - 1 mL/5 TU 10 tests) |      |6506-3311-0 |     |      |

|DIPLOID |Rabies Human Diploid Vaccine (1 x 1.0 mL) |      |6571-3231-0 |     |      |

|(Rabies) | | | | | |

|RIG (Rabies) |Rabies Immune Globulin (Human - 2.0 mL vial) |      |6571-3225-0 |     |      |

|ELEMENT |Tetanus and Diphtheria Toxoids and Inactivated Poliomyelitis Vaccine Adsorbed (Td |      |6571-3249-0 |     |      |

|(Td Polio) |Polio - 5 x 0.5 mL) | | | | |

|HEP A (Adult) |Hepatitis A Vaccine (adult - 1 dose syringe 1 mL) |      |6571- 3257-0 |     |      |

|HEP A (Paed) |Hepatitis A Vaccine (paediatric - 1 dose syringe 0.5 mL) |      |6571- 3256-0 |     |      |

|HEP B |Hepatitis B Vaccine (adult - 1 mL vial) |      |6571-3243-0 |     |      |

|ADULT | | | | | |

|HEP B |Hepatitis B Vaccine (paediatric - 0.5 mL vial) |      |6571-3251-0 |     |      |

|PAED | | | | | |

|HEP B REN |Hepatitis B Vaccine (renal dialysis - 1 mL vial) |      |6571-3324-1 |     |      |

|(RECOMBIVAX) | | | | | |

|Meningococcal |Meningococcal C Conjugate Vaccine (single dose - 1 x 0.5 mL) |      |6571-3344-0 |     |      |

|C Conjugate | | | | | |

|(Menjugate®) | | | | | |

|Meningococcal |Meningococcal C Conjugate Vaccine (multi dose – 5 x 0.5 mL) |      |6571-3344-2 |     |      |

|C Conjugate | | | | | |

|(Menjugate®) | | | | | |

|MMR |Measles, Mumps and Rubella Virus Vaccine (MMR - 10 x 0.5 mL) |      |6571-3230-0 |     |      |

|OCEAN (IPV) |Inactivated Poliomyelitis Vaccine (IPV - 5 x 0.5 mL) |      |6571-3220-0 |     |      |

|PENTACE |cPDT-Polio Vaccine (Quadracel®) to reconstitute Haemophilus b Conjugate Vaccine |      |6571-3348-0 |     |      |

|(PENTACEL®) |(Act-HIB®) (5 x 0.5 mL) | | | | |

|PNEUMO1 |Pneumococcal Vaccine, Polyvalent (1 x 0.5 mL) |      |6571-4010-1 |     |      |

|PREVNAR® |Pneumococcal Heptavalent Conjugate Vaccine (10 x 0.5 mL prefilled syringes) |      |6571-2202-2 |     |      |

|SOUND (Td) |Tetanus and Diphtheria Toxoids Adsorbed (Td - 5 x 0.5 mL) |      |6571-3240-0 |     |      |

|SPACE |Component Pertussis Vaccine Diphtheria and Tetanus Toxoids Adsorbed combined with |      |6571-3343-0 |     |      |

|(QUADRACEL®) |Inactivated Poliomyelitis Vaccines (cPDT-Polio - 5 x 0.5 mL) | | | | |

|Influenza |Inactivated Influenza (5 mL vial) |      |6571-3323-0 |     |      |

|TALL |Haemophilus b Conjugate Vaccine for the prevention of Haemophilus influenzae type |      |6571-3255-0 |     |      |

|(Act-HIB®) |b disease among infants (5 x 0.5 mL) | | | | |

|Varicella Vaccine |Varicella Virus Vaccine, Live, Attenuated (Varivax III® - 1 x 0.5 mL) |      |6571-3305-1 |     |      |

|(Varivax III®) | | | | | |

|Varicella Vaccine |Varicella Virus Vaccine, Live, Attenuated (VarilrixTM - 10 x 0.5 mL) |      |6571-3308-1 |     |      |

|(VarilrixTM) | | | | | |

|Vaccines not listed |

|      |      |      |      |     |      |

|      |      |      |      |     |      |

|*Return Codes: |

|[XP] Cold chain break – physician office [OG] Outdated Goods [ER] Power outage |

|[UP] Unsuitable for use (e.g. broken) |

| |

3296-64 (06/08) © Queen’s Printer for Ontario, 2006 7530-5536

|[pic] |Ministère de la Santé |Service d’approvisionnement |Fiche de renvoi de vaccin |

| |et des Soins de longue durée |médico-pharmaceutique |non réutilisable |

| | |du gouvernement de l’Ontario |(altéré ou périmé) |

| | |99 Adesso Drive |Clients de Toronto |

| | |Concord (Ontario) L4K 3C7 | |

| | |Tél. (416) 327-0837 | |

| | |Téléc. (416) 327-0818 | |

| | | | |

|S’adresser au Service d'approvisionnement médico-pharmaceutique du gouvernement de l'Ontario (SAMPGO) pour obtenir un numéro d’autorisation de renvoi. |

|Apposer la formule dûment remplie et/ou l’autocollant du vaccin non réutilisable à l’extérieur de l’emballage. |

|Remettre au livreur du SAMPGO au moment de la livraison de la prochaine commande. |

|Nom du client |Numéro de client |No d’autorisation de renvoi |

|      |      |      |

|Renvoyé par |Numéro de téléphone |Date du renvoi (aaaa-mm-jj) |

|      |      |      |

|Nom de code |Description |No de lot |No de cat. |Nbre |*Raison |

| | | | |d’embal. |du renvoi |

|ADACEL® |Anatoxines tétanique et diphtérique adsorbées combinées à un vaccin |      |6571-2203-0 |     |      |

| |anticoquelucheux composé (5 x 0,5 mL) | | | | |

|BID (Mantoux) |Tuberculine dérivée de protéines purifiées 5 TU (Mantoux - 1 mL/5 TU tests de 10)|      |6506-3311-0 |     |      |

|DIPLOID (rage) |Vaccin antirabique sur cellules diploïdes humaines (flacon de 1 mL) |      |6571-3231-0 |     |      |

|RIG (rage) |Immunoglobuline antirabique (humaine - flacon de 2 mL) |      |6571-3225-0 |     |      |

|ELEMENT |Anatoxines tétanique et diphtérique et vaccin antipoliomyélitique inactivé |      |6571-3249-0 |     |      |

|(dT Polio) |adsorbés (dT Polio – 5 x 0,5 mL) | | | | |

|HEP A (adulte) |Vaccin contre l’hépatite A (adulte – seringue dose unique 1 mL) |      |6571- 3257-0 |     |      |

|HEP A (enfant) |Vaccin contre l’hépatite A (enfant – seringue dose unique 0,5 mL) |      |6571- 3256-0 |     |      |

|HEP B |Vaccin contre l’hépatite B (adulte – flacon 1 mL) |      |6571-3243-0 |     |      |

|ADULTE | | | | | |

|HEP B |Vaccin contre l’hépatite B (enfant – flacon 0,5 mL) |      |6571-3251-0 |     |      |

|ENFANT | | | | | |

|HEP B REN |Vaccin contre l’hépatite B (dialyse rénale – flacon 1 mL) |      |6571-3324-1 |     |      |

|(RECOMBIVAX) | | | | | |

|Meningococcal |Vaccin conjugué contre le méningocoque de souche C (dose unique - 1 de 0,5 mL) |      |6571-3344-0 |     |      |

|C Conjugate | | | | | |

|(Menjugate®) | | | | | |

|Meningococcal |Vaccin conjugué contre le méningocoque de souche C (doses multiples - 5 de |      |6571-3344-2 |     |      |

|C Conjugate |0,5 mL) | | | | |

|(Menjugate®) | | | | | |

|MMR |Vaccin antirougeuleux, antiourlien et antirubéoleux (ROR - 10 x 0,5 mL) |      |6571-3230-0 |     |      |

|OCEAN (VPI) |Vaccin antipoliomyélitique inactivé (VPI - 5 x 0,5 mL) |      |6571-3220-0 |     |      |

|PENTACE |Vaccin cCDT-Polio (Quadracel®) pour reconstituer le vaccin conjugué contre |      |6571-3348-0 |     |      |

|(PENTACEL®) |l’Haemophilus b (Act-HIB®) (5 x 0,5 mL) | | | | |

|PNEUMO1 |Vaccin antipneumococcique polyvalent (1 x 0,5 mL) |      |6571-4010-1 |     |      |

|PREVNAR® |Vaccin antipneumococcique conjugué heptavalent (10 seringues préremplies de |      |6571-2202-2 |     |      |

| |0,5 mL) | | | | |

|SOUND (dT) |Anatoxines tétanique et diphtérique adsorbées (dT - 5 x 0,5 mL) |      |6571-3240-0 |     |      |

|SPACE |Vaccin à base de composant Pertussis et diphthérique et tétanique adsorbées |      |6571-3343-0 |     |      |

|(QUADRACEL®) |combiné au vaccin antipoliomyélitique inactivé | | | | |

| |(cCDT-Polio - 5 x 0,5 mL) | | | | |

|Influenza |Vaccin grippal inactivé (flacon de 5 mL) |      |6571-3323-0 |     |      |

|TALL |Vaccin conjugué contre l’Haemophilus b (5 x 0,5 mL) |      |6571-3255-0 |     |      |

|(Act-HIB®) | | | | | |

|Varicella Vaccine |Vaccin à virus vivant atténué contre la varicelle (Varivax III® - 1 x 0,5  mL) |      |6571-3305-1 |     |      |

|(Varivax III®) | | | | | |

|Varicella Vaccine |Vaccin à virus vivant atténué contre la varicelle (VarilrixTM - 10 x 0,5 mL) |      |6571-3308-1 |     |      |

|(VarilrixTM) | | | | | |

|Vaccins non énumérés |

|      |      |      |      |     |      |

|      |      |      |      |     |      |

|* Codes de renvoi : |

|[XP] Rupture dan la chaîne du froid – cabinet médical [OG] Vaccin périmé [ER] Panne d’électricité |

|[UP] Vaccin non utilisable (p. ex. brisé) |

3296-64 (06/08) © Imprimeur de la Reine pour l’Ontario, 2006 7530-5536

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