VACCINES FOR CHILDREN (VFC) PROGRAM …

1 VACCINES FOR CHILDREN (VFC) PROGRAM vaccine ordering worksheet IMM -124 6 (7-18)Instructions: Complete the worksheet that matches your provider category ( , low-, medium-, or high-volume) before submitting routine vaccine orders. Refer to the VFC PROGRAM Provider Operations Manual as , conduct a physical vaccine inventory to determine the doses on hand. Remove the first VACCINES from the storage unit and group by lot numbers. Note the vaccine brand, lot numbers, and expiration dates in columns A, B, and C of the worksheet . Count all doses of that lot number and write the # Doses on Hand in column D. Repeat for each lot number. Add up the doses in column D and write the Tota l D ose s on Hand in column those VACCINES to the storage unit and repeat for all VFC VACCINES before completing the rest of this worksheet .

2 Determine the total doses administered since your previous order. Record the Total Doses Administered in column E. Using an immunization registry or EHR/EMR? Run usage reports to filter VFC VACCINES administered. Otherwise, if using VFC Daily Usage Log (IMM-1053): A. Add up the Daily Total for all copies of the usage logs completed since your previous order. B. Record the Total Doses Administered in column E (see below). Calculate the total doses to order. Calculate and write the Estimated Need in column G. A. Multiply column E by column F. B. Write the number in column and write the # Doses in column I. A. Calculate column G minus column H.

3 B. Write the number in column I. Round up and write the Tota l D ose s to Order in column J. A. If the number in column I is negative (such as ), write 0 in column J. B. Otherwise, round up to the nearest order quantity (doses/box) and write the number in column your order on using the information from this worksheet . Remember: Report doses administered (since the previous order) and doses on hand (at the time of the order) for all VFC VACCINES even if you re not ordering new doses. Don t forget to process returns and transfers. California Department of Public Health, Immunization Branch11123234 ESTIMATED NEEDESTIMATED NEEDVACCINEBRANDDOSES PER BOXLOT NUMBERSEXPIRA-TION D AT E# DOSESON HANDTOTAL DOSES ADMINISTEREDSAFETY STOCKESTIMATED NEED TOTAL DOSES ON HAND(total column D)

4 # DOSES TOTA L DOSES TO ORDER DTa Px = =DTa P- HepB- IPVx = =DTaP- IPVx = =DTa P-IPV/ Hibx = =HepAx = =HepBx = =Hibx = =HPVx = =IPVx = =MCV4x = =MenBx = =PCV13x = =* Highlights indicate special order VFC vaccinesVACCINES FOR CHILDREN (VFC) PROGRAM vaccine ordering worksheet Instructions: Complete this worksheet using the attached instructions before ordering routine VACCINES on Be sure to use the sheet that corresponds to your provider.

5 IMM-1246 (7/18)REFRIGERATORA B C D E F G H I JDaptacel vialsInfanrix vialsInfanrix syringesPediarix syringesKinrix vialsKinrix syringes Quadracel vialsActHIB vials Hiberix-vialsPedvaxHIB vials Pentacel vialsVAQTA vialsHavrix vialsHavrix syringesEngerix-B vialsEngerix-B syringesRecombivax HB vialsGardasil 9 vialsIPOL vialsMenactra vialsMenveo vialsBexsero syringes* Trumenba syringes*Prevnar 13 syringes10101051010101010101010551010101 05 105 1010 Low-Volume ProvidersVACCINEBRANDDOSES PER BOXLOT NUMBERSEXPIRA-TION D AT E# DOSES ON HANDTOTAL

6 DOSES ADMINISTEREDSAFETY STOCKESTIMATED NEEDTOTAL DOSES ON HAND(total column D) # DOSES TOTA L DOSES TO ORDER PPSV23x = = RVx = =Tdx = =Tdapx = = MMRx = = MMRVx = =VARx = =* Highlights indicate special order VFC vaccinesVACCINES FOR CHILDREN (VFC) PROGRAM vaccine ordering worksheet Instructions: Complete this worksheet using the attached instructions before ordering routine VACCINES on Be sure to use the sheet that corresponds to your provider.

7 California Department of Public Health, Immunization Branch IMM-1246 (7/18)REFRIGERATORFREEZERA B C D E F G H I JRotarix vialsRotaTeq tubesRotaTeq tubesMMR-II vialsTenivac vials* Tenivac syringes*Td vaccine (Grifols) vials*ProQuad vialsAdacel vialsAdacel syringesBoostrix vialsBoostrix syringesVarivax vials1010251010 10 101010510101010 Low-Volume ProvidersPneumovax 23 vials*Remember to report returns and transfers before submitting your order on using the information from this ProvidersVACCINEBRANDDOSES PER BOXLOT NUMBERSEXPIRA-TION D AT E# DOSESON HANDTOTAL DOSES ADMINISTEREDSAFETY STOCKESTIMATED NEED TOTAL DOSES ON HAND(total column D)

8 # DOSES TOTA L DOSES TO ORDER DTa Px = =DTa P- HepB- IPVx = =DTaP- IPVx = =DTa P-IPV/ Hibx = =HepAx = =HepBx = =Hibx = =HPVx = =IPVx = =MCV4x = =MenBx = =PCV13x = =* Highlights indicate special order VFC vaccinesVACCINES FOR CHILDREN (VFC) PROGRAM vaccine ordering worksheet Instructions: Complete this worksheet using the attached instructions before ordering routine VACCINES on Be sure to use the sheet that corresponds to your provider.

9 IMM-1246 (7/18)REFRIGERATORA B C D E F G H I JDaptacel vialsInfanrix vialsInfanrix syringesPediarix syringesActHIB vials Hiberix-vialsPedvaxHIB vials Pentacel vialsVAQTA vialsHavrix vialsHavrix syringesEngerix-B vialsEngerix-B syringesRecombivax HB vialsGardasil 9 vialsIPOL vialsMenactra vialsMenveo vialsBexsero syringes* Trumenba syringes*Prevnar 13 syringes10101051010101010101010551010105 1010 Kinrix vialsKinrix syringes Quadracel vials105 10 Medium-Volume ProvidersVACCINEBRANDDOSES PER BOXLOT NUMBERSEXPIRA-TION D AT E# DOSES ON

10 HANDTOTAL DOSES ADMINISTEREDSAFETY STOCKESTIMATED NEEDTOTAL DOSES ON HAND(total column D) # DOSES TOTA L DOSES TO ORDER PPSV23x = = RVx = =Tdx = =Tdapx = = MMRx = = MMRVx = =VARx = =* Highlights indicate special order VFC vaccinesVACCINES FOR CHILDREN (VFC) PROGRAM vaccine ordering worksheet Instructions: Complete this worksheet using the attached instructions before ordering routine VACCINES on Be sure to use the sheet that corresponds to your provider.