2020 HEPATITIS VACCINE
SEMI-ANNUAL USAGE REPORT
SFDPH Communicable Disease Prevention Unit
Email immunization.dph@sfdph.org
SFDPH Communicable Disease Prevention Unit 101 Grove Street, Room 406 San Francisco CA 94102
Email immunization.dph@sfdph.org
Organization Name:_______________________________ Reporting Period: Jan 1-June 30 July 1-Dec 31
Please report the total number of Hepatitis A, B, and combined A & B doses awarded, administered, wasted, unaccounted, and
remaining in inventory during the specified period above. Please provide information only on doses of Hepatitis vaccine
supplied to you by the San Francisco Department of Public Health (SFDPH) Immunization Program.
Breakdown of Hepatitis vaccine recipients by AGE:
Please use this space to explain wasted vaccine doses:
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Please use this space to explain unaccounted for vaccine doses:
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Please describe your clinic workflow for conducting HbsAg and anti-HBs testing prior to vaccination for persons who are from areas
where chronic HBV is considered endemic:______________________________________________________________________
________________________________________________________________________________________________________________
Person completing report:
Name Title
SIGNATURE Date
Phone # Fax # Email
Vaccine Hep A Hep B Hep A/B
Lot Number:
1. Doses awarded to your organization during reporting period
2. Total doses administered to your clients during reporting period
Administered: doses your practice successfully administered to patients
3. Doses wasted during reporting month (explain below)
Wasted: doses your practice did not use because of: temperature excursions; broken
syringes; vaccines prepared but not administered; and/or the vaccines expired
4. Total doses unaccounted for during reporting month (explain below)
Unaccounted for: doses awarded to your practice that cannot be located and have not
been recorded as wasted or administered
5. Total doses remaining in your inventory on the last day of reporting month
Remaining: unexpired, viable doses awarded by SFDPH that your practice still has.
Vaccine Lot # 19-49 YEARS 50-64 YEARS 65 YEARS + TOTAL
Hep A
Hep B
Hep A/B
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