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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