2016 MnVFC Site Visit Storage & Handling Per Unit Answer Sheet
MnVFC PIN:
Question number and
content area
Unit description – Brand:
Location:
4.1A Type of unit
☐ Stand-alone
☐ Combination
4.1B Use if stand-alone
☐ Refrigerator
☐ Freezer
4.1B Use if combination
☐ Both sections
☐ Refrigerator only
☐ Freezer only
4.2
☐ Pharmaceutical
☐ Commercial/household
[O] CDC does not
recommend using both
sections of household units
Select grade
Temperature Monitoring Device Questions: Questions 4.3-4.7 must be answered separately for the freezer and
refrigerator if the unit is a combo. Be sure to document responses in the appropriate column.
Storage unit section
Refrigerator
Freezer
4.3A Temperature monitoring device
in this section?
☐ Yes
☐ No [X] (if no, skip to 4.7)
☐ Yes
☐ No [X] (if no, skip to 4.7)
4.4A Continuous monitoring and
recording device
☐ Yes
☐ No [O] (if no, skip question D)
☐ Yes
☐ No [O] (if no, skip question D)
4.4B Have a probe in buffered solution
☐ Yes
☐ No [O]
☐ Yes
☐ No [O]
4.4C Digital display that can be read
from outside the unit
☐ Yes
☐ No [O]
☐ Yes
☐ No [O]
4.4D Data downloaded and reviewed
routinely (e.g., weekly)
☐ Yes
☐ No [O]
☐ Yes
☐ No [O]
4.5A Certificate of Calibration Testing
for section
☐ Yes
☐ No [X]
☐ Yes
☐ No [X]
4.5B Date certificate expires
☐ [X] Follow-up is required if expired
☐ [X] Follow-up is required if expired
4.5C Certificate contains all necessary ☐ Yes
items
☐ No [X]
☐ Yes
☐ No [X]
☐ Yes
☐ No [X]
☐ Yes
☐ No [X]
☐ Yes
☐ No [X]
☐ Yes
☐ No [X]
4.7B Time, date and name (or initials) ☐ Yes
for each reading
☐ No [X]
☐ Yes
☐ No [X]
4.6
Probe properly placed in section
4.7A Two temperature readings for
each section per day
4.7C Current temperature in this
section
°
☐ Fahrenheit
☐ Celsius
☐ Yes
4.7D Section maintaining appropriate
☐ No [X]
temperatures
☐ Not enough info [X]
°
☐ Fahrenheit
☐ Celsius
☐ Yes
☐ No [X]
☐ Not enough info [X]
(May 2016) Page 1 of 2
VFC SITE VISIT STORAGE & HANDLING PER UNIT ANSWER SHEET
Question number and
content area
Unit description – Brand:
Location:
End of temperature monitoring device questions
Answer questions 4.8-4.10 for the unit as a whole rather than for individual sections (if a combination unit)
4.8A Vaccines exposed to any out-ofrange temperatures in last 3
months (including today)
☐ Yes
☐ No (if no, skip to question 4.8F)
4.8B Quarantine and label vaccines
“do not use”?
☐ Yes
☐ No [X]
4.8C Move vaccine to a unit with
proper temps
☐ Yes
☐ No [X]
4.8D Report to the immunization
program
☐ Yes
☐ No [X]
4.8E Manufacturer contacted about
usability of the vaccine
☐ Yes
☐ No [X]
4.8F Any further action needed to
determine usability of the
vaccine
☐ Yes [X]
☐ No
4.9A Vaccines placed in the middle of
the unit with space for air
circulation
☐ Yes
☐ No [O]
4.9B Vaccine stored in original
packaging
☐ Yes
☐ No [O]
4.9C Water bottles in fridge and
frozen water bottles in freezer
☐ Yes
☐ No [O]
4.9D Vaccines stored in doors, bins,
near vents or on floor
☐ Yes [O]
☐ No
4.9E Food stored in unit
☐ Yes [O]
☐ No
4.10 Steps being taken to prevent
units from accidently being
disconnected from the power
supply
☐ A. Do not disconnect labels on plug
☐ B. Warning labels on circuit breakers
☐ C. Hard-wired (built-in) and label on circuit breaker
[X] The response is non-compliant
☐ D. Hospital or large health care system with
if only A, B, or E is selected.
comprehensive written policy and procedures
☐ E. No acceptable measures for preventing accidental
disconnection from power supply [X]
Notes:
Save each Storage & Handling Per Unit Answer Sheet with the Brand + Location in the file name
(example: Samsung.Room123.doc).
(May 2016) Page 2 of 2