REFRIGERATOR TEMPERATURE MONITORING LOG: Days 1-15 …

1 0. 1. 2. 3. 1. 2a. 2. 3. 4. 123456789101112131415ampmampmampmampmamp mampmampmampmampmampmampmampmampmampmamp m DATE F / C1/148 FTemperatureRefrigerator , Action Taken: Fridge control adjusted, contacted manufacturers- vaccine viable, case #123456 Take action if temp is out of range-too warm (above 46 F / 8 C) or too cold (below 36 F/ 2 C):Label exposed vaccine do not use, and store it under proper conditions as quickly as possible.

2 Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health the out-of-range temps and the room temp in the Action area on the bottom of the your vaccine coordinator and follow the Vaccine TEMPERATURE Excursion Guide. For more information, visit: > Storage and HandlingRoom TempFRIDGE NAME/NUMBER:_____MONTH & YEAR:_____ 46 F (8 C) 45 F ( C) 44 F ( C) 43 F ( C) 42 F ( C) 41 F ( C) 40 F ( C) 39 F ( C) 38 F ( C) 37 F ( C)NotesRefrigeratorExact Time of TempPlease list steps taken to address TEMPERATURE /storage unit issues.

3 Include manufacturer's determination and case number(s). 36 F (2 C) 35 F ( C) 34 F ( C) 33 F ( C) 32 F ( C) 49 F ( C) 48 F ( C) 47 F ( C)If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711). DOH 348-077 March 2022 CLINIC NAME:_____ActionStaff InitialsINSTRUCTIONS ON HOW TO RECORD TEMPERATURES: Enter Provider Information and circle if you are recording in C or F on the TEMPERATURE log.

4 Write your initials below in Staff Initials, and note the time in Exact Time. Record min/max once each workday (since previous recording), preferably in the morning. Record current temps twice, at beginning and end of each an X in the row that corresponds to the REFRIGERATOR s any out-of-range temp , see instructions to the each month has ended, save each month s log for 3 of MonthMin/Max temp F C PROVIDER PIN:_____REFRIGERATOR TEMPERATURE MONITORING LOG: Days 1-15 AIM for0. 1. 2. 3. DATE F / C1/148F 37 F ( C) 49 F ( C) 48 F ( C) 47 F ( C) 46 F (8 C)F C PROVIDER PIN:_____MONTH & YEAR:_____Action 45 F ( C) 44 F ( C) 43 F ( C) 42 F ( C)TemperatureRefrigerator 36 F (2 C) 35 F ( C) 34 F ( C) 33 F ( C) 32 F ( C) 41 F ( C) 40 F ( C) 39 F ( C) 38 F ( C)Please list steps taken to address TEMPERATURE / storage unit issues.

5 Include manufacturer's determination and case number(s). , Action Taken: Fridge control adjusted, contacted manufacturers- vaccine viable, case #123456If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711). DOH 348-077 March 2022 REFRIGERATOR TEMPERATURE MONITORING LOG: Days 16-31 FRIDGE NAME/NUMBER:_____CLINIC NAME:_____INSTRUCTIONS ON HOW TO RECORD TEMPERATURES:Circle if you are recording in C or F on the TEMPERATURE log. Write your initials below in Staff Initials, and note the time in Exact Time.

6 Record min/max once each workday (since previous recording), preferably in the morning. Record current temps twice, at beginning and end of each an X in the row that corresponds to the REFRIGERATOR s any out-of-range temp , see instructions to the each month has ended, save each month s log for 3 action if temp is out of range - too warm (above 46 F / 8 C) or too cold (below 36 F / 2 C):1. Label exposed vaccine do not use, and store it under proper conditions as quickly as possible. Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health Record the out-of-range temps and the room temp in the Action area Notify your vaccine coordinator and follow the Vaccine TEMPERATURE Excursion more information, visit: > Storage and HandlingNotesDay of MonthMin/Max temp RefrigeratorExact Time of TempRoom TempStaff InitialsAIM for0.

7 1. 2. 3. DATE F / C1 , Action Taken: Freezer control adjusted, contacted Merck- vaccine viable, case #12345. Freezer TemperatureF C 8 F ( C) -4 F ( C) 7 F ( C) 6 F ( C) 5 F ( C) 4 F ( C) 3 F ( C) ActionPlease list steps taken to address TEMPERATURE / storage unit issues. Include manufacturer's determination and case number(s). 2 F ( C) -5 F ( C) -6 F ( C) -7 F to -57 F -58 F (-50 C) 1 F ( C) 0 F ( C) -1 F ( C) -2 F ( C) -3 F ( C) If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).

8 DOH 348-077 March 2022 FREEZER TEMPERATURE MONITORING LOG: Days 1-15 NotesDay of MonthMin/Max temp FreezerExact Time of TempRoom TempStaff InitialsINSTRUCTIONS ON HOW TO RECORD TEMPERATURES:Circle if you are recording in C or F on the TEMPERATURE log. Write your initials below in Staff Initials, and note the time in Exact Time. Record min/max once each workday (since previous recording), preferably in the morning. Record current temps twice, at beginning and end of each an X in the row that corresponds to the freezer s any out-of-range temp , see instructions to the each month has ended save each month s log for 3 yearsTake action if temp is out of range - too warm (above 6 F / C) or too cold (below -57 F /-50 C):1.

9 Label exposed vaccine do not use, and store it under proper conditions as quickly as possible. Do not discard vaccines unless directed to by the manufacturer(s) and/or your state health department. 2. Record the out-of-range temps and the room temp in the Action area Notify your vaccine coordinator and follow the Vaccine TEMPERATURE Excursion NAME/NUMBER:_____CLINIC NAME:_____PROVIDER PIN:_____MONTH & YEAR:_____0.

10 1. 2. 3. 1. 2. 3. 4. 16171819202122232425262728293031ampmampm ampmampmampmampmampmampmampmampmampmampm ampmampmampmampm DATE F / C1/110F 3 F ( C) , Action Taken: Freezer control adjusted, contacted Merck- vaccine viable, case #12345. 8 F ( C) 7 F ( C) 6 F ( C) 5 F ( C) 4 F ( C) Freezer TEMPERATURE -7 F to -57 F -3 F ( C) -58 F (-50 C) -2 F ( C) -4 F ( C) -5 F ( C) -6 F ( C) 2 F ( C) 1 F ( C) 0 F ( C) -1 F ( C) If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).