Vaccine Return Form

Vaccine Return Form

Please complete this Vaccine Return Form for any vaccine eligible for return by the Providers . The clinic will be financially responsible for annual vaccine lost/wastage greater than 5%. Amounts entered on this form must match what is entered into MIIX. Amounts entered on this form must match amount of vaccine placed in shipping box for return to McKesson.

Facility Name*

VFC Facility PIN*

Select

Contact Name*

Contact Phone Number*

Phone

Contact Email*

Return Label will be sent to this email address.

How many shipping labels do you need for return?*

For all the returns you are reporting today.

Vaccine Name*

Select

Vaccine NDC Number*

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

Select

Vaccine Lot Number*

Vaccine Expiration Date*

Number of Doses to Return*

Funding Source*

VFC

CHIP

State Pediatric

State Adult

317

Vaccine Return Reason*

Refrigerator or Freezer malfunction

Left out of Refrigerator or Freezer

Improper Storage

Expired Vaccine

Damaged In Transit

Vaccine Recall

Power Outage

Natural Disaster

Other- please specify

Other - Please specify*

More Vaccine to Return?*

Yes

No

Vaccine 2 - Name*

Select

Vaccine 2 - NDC Number*

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

Select

Vaccine 2 - Lot Number*

Vaccine 2 - Expiration Date*

Vaccine 2 - Number of Doses to Return*

Vaccine 2 – Funding Source*

VFC

CHIP

State Pediatric

State Adult

317

Vaccine 2 – Return Reason*

Refrigerator or Freezer malfunction

Left out of Refrigerator or Freezer

Improper Storage

Expired Vaccine

Damaged In Transit

Vaccine Recall

Power Outage

Natural Disaster

Other- please specify

Vaccine 2 – Specify Other Reason*

I have more Vaccine to Return?*

Yes

No

Vaccine 3 – Name*

Select

Vaccine 3 - NDC Number*

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

Select

Vaccine 3 - Lot Number*

Vaccine 3 - Expiration Date*

Vaccine 3 – Number of Doses to Return*

Vaccine 3 – Funding Source*

VFC

CHIP

State Pediatric

State Adult

317

Vaccine 3– Return Reason*

Refrigerator or Freezer malfunction

Left out of Refrigerator or Freezer

Improper Storage

Expired Vaccine

Damaged In Transit

Vaccine Recall

Power Outage

Natural Disaster

Other- please specify

Vaccine 3 – Specify Other Reason*

I have another vaccine to return*

Yes

No

Vaccine 4 – Name*

Select

Vaccine 4 - NDC Number*

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

Select

Vaccine 4 - Lot Number*

Vaccine 4 - Expiration Date*

Vaccine 4 – Number of Doses to Return*

Vaccine 4 – Funding Source*

VFC

CHIP

State Pediatric

State Adult

317

Vaccine 4 – Return Reason*

Refrigerator or Freezer malfunction

Left out of Refrigerator or Freezer

Improper Storage

Expired Vaccine

Damaged In Transit

Vaccine Recall

Power Outage

Natural Disaster

Other- please specify

Vaccine 4 – Specify Other Reason

Another vaccine to return?*

Yes

No

Vaccine 5 - Name*

Select

Vaccine 5 - NDC Number*

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

Select

Vaccine 5 - Lot Number*

Vaccine 5 - Expiration Date*

Vaccine 5 – Number of Doses to Return*

Vaccine 5 – Funding Source*

VFC

CHIP

State Pediatric

State Adult

317

Vaccine 5 – Return Reason*

Refrigerator or Freezer malfunction

Left out of Refrigerator or Freezer

Improper Storage

Expired Vaccine

Damaged In Transit

Vaccine Recall

Power Outage

Natural Disaster

Other- please specify

Vaccine 5 – Specify Other Reason*

Additional Vaccine to Return?*

Yes - Please complete form again to report additional wastage.

No

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