HEALTH CARE CENTERS IN SCHOOLS
SCHOOL-WIDE FLU IMMUNIZATION PROGRAM
DAILY REPORT OF VACCINE MOVEMENT, TEMPERATURE, AND DOSES GIVEN
SCHOOL __________________________________
Date _____________________
Type of
Vaccine
Number of
Doses in Ice
Chest
Project Coordinator _____________________
Runner _________________
Number
of Doses
Given
Number of
Doses
Returned
Site RN ___________________
Number of
Doses Not
Used*
GRAND TOTAL-should equal
the # of doses
in ice chest
VFC Flumist
VFC
Injectable
Vaccine
NON-VFC
Flumist
NON-VFC
Injectable
Vaccine
GRAND
TOTAL
*Any doses not given or drawn up in a syringe and not given MUST be accounted for in this program. Please explain
below.
Type of Vaccine
Explanation
VFC Flumist
VFC Injectable
Vaccine
NON-VFC
Flumist
NON-VFC
Injectable Vaccine
Temperature upon arrival at school of the ice chest--Vaccines For Children ____________
Temperature upon arrival at school of the ice chest--NON-VFC Vaccine _______________
Temperature upon arrival at warehouse of the ice chest--Vaccines For Children ____________
Temperature upon arrival at warehouse of the ice chest--NON-VFC Vaccine _______________
Signature of Site RN ___________________
Signature of Project Coordinator ________________
Signature of Runner ___________________
Signature of Coordinator ______________________