Cold Chain Break Report - Alberta Health Services
|Part A | | |
|Date Break Occurred (yyyy-Mon-dd) |Date of Report (yyyy-Mon-dd) |Reporter Name |
| | | |
|Telephone Number |Fax Number |Reporter Email Address |
| | | |
|Location of Break (City/Town, Facility Name, Fridge # if applicable) |Alberta Vaccine Inventory (AVI) PIN # |
| | |
|Facility Type |Type of Cold Chain Break |
|Pharmacy Public Health Physician Office |Temperature excursion (less than +2.00C or greater than +8.00C) |
|LTC Acute Care |Light Exposure |
|Private Agency (e.g. WeCare, Shell) |No or incomplete temperature monitoring |
|Other (specify) | |
| |AHS Zone South Calgary Central |
| |Edmonton North |
|AHS Zone Vaccine Contact |Telephone Number |Fax Number |
| | | |
|Description of Break |
|Are products now quarantined, labeled “do not use”, and in a functioning, monitored fridge between +2.0°C and +8.0°C? |
|Yes No (If no, explain) |
|Vaccine returned to storage between 2.00C and 8.00C |date (yyyy-Mon-dd) |time (hh:mm) |
|Last temperature recorded before the break | 0C |date (yyyy-Mon-dd) |time (hh:mm) |
|Current temperature at time break identified | 0C |date (yyyy-Mon-dd) |time (hh:mm) |
|Maximum temperature recorded during interval | 0C |Minimum temperature recorded during interval | 0C |
|Time out of cold chain |Attach temperature monitoring log, chart tracing and data logger |
| hours mins |report as applicable |
|Refrigerator Type |Thermometer/Monitor Type (not brand name) |
|Lab Fridge Domestic Fridge |Digital Min/Max Chart Recorder Data Logger |
|Other (specify) |Warm/Cold Mark No Monitor |
| |Other (specify) |
|Cause of Cold Chain Break (check all that apply) |Products involved in previous breaks |
|Human Error |No |
|Thermometer Malfunction |Yes date (yyyy-Mon-dd) |
|Power Outage |location |
|Refrigerator Malfunction |date (yyyy-Mon-dd) |
|Other (specify) |location |
| |If some products have been involved in a previous break(s), report those doses using a separate Part B of|
| |the Cold Chain Break Report. |
|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? No |
|Yes – clearly indicate these products |
|Part B | | |
|Date Break Occurred (yyyy-Mon-dd) |Location of Break |
| | |
|Alberta Health publicly-funded |Count |Lot # |
|vaccine ONLY | | |
|Date Break Occurred (yyyy-Mon-dd) |Location of Break |
| | |
|Alberta Health publicly-funded |
|vaccine ONLY |
|Part C – AHS Facilities Only | | |
|Date Break Occurred (yyyy-Mon-dd) |Location of Break |
| | |
Purchased ProductCountLot #CountLot #CDC Use OnlyIf more than 2 lot numbers
use separate page(s)If more than 2 lot numbers
use separate page(s)ViableNot ViableSingle Dose PreparationsDosesDosesdTap - 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 Herpes Zoster- SHINGRIX 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 PreparationsNumber of VialsDoses RemainingLot NumberViableNot ViableTuberculin - TUBERSOL (5TU)Open Sealed[pic]
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