Vaccine Wastage and Disposed Reporting

Please complete this Wastage and Disposed form for any vaccine that is Wasted and Disposed of by Publicly Funded Vaccine Providers. Providers will be financially responsible for annual vaccine lost/wasted greater then 5%. Amounts entered in this form must match what is being entered into MIIX.


Only 1 Funding Source is allowed per entry. If you are reporting waste for VFC and CHIP vaccines, then you must fill out 2 separate forms.

 
 
 
Phone
 
 
 

Use the 11-digit NDC on the Box. Contact the immunizations office at 601-576-7751 if you need assistance.

 
 
 
mm/dd/yyyy
 
 

Only 1 Funding Source allowed per entry