Fillable STATE/FEDERAL INFLUENZA VACCINE, MID YEAR USAGE REPORT, 2020-21 (Disease Prevention & Control - San Francisco Department of Public Health)

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STATE/FEDERAL INFLUENZA VACCINE, MID YEAR USAGE REPORT, 2020-21 (Disease Prevention & Control - San Francisco Department of Public Health)

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STATE/FEDERAL INFLUENZA VACCINE, MID YEAR USAGE REPORT, 2020-21
Complete and Return to immunization.dph@sfdph.org by Friday, January 22, 2021
SFDPH Communicable Disease Prevention Unit
Complete and Return to immunization.dph@sfdph.org by Friday, January 22, 2021
SFDPH Communicable Disease Prevention Unit 101 Grove Street, Room 406 San Francisco CA 94102
Organization Name:_____________________________________________________________________________________
Total doses awarded to your practice: ______________________________________________________________________
Lot number(s)/expiration date(s) of vaccine: ________________________________________________________________
For questions 1-3, please provide information on doses of flu vaccine supplied to you only by the San Francisco Department of
Public Health (SFDPH). Please report usage numbers for all doses recived from SFDPH. Do NOT include VFC vaccine or
vaccine received from any other sources.
Definitions
Awarded: doses your practice received from SFDPH
Administered: doses your practice successfully provided to patients
Wasted: doses your practice did not use because of: temperature excursions; broken vials/syringes; vaccines were drawn but not
administered; vials were opened but not all doses were used; and/or the vaccines expired (expired vaccine your practice still has
in its possession is considered “wasted”)
Unaccounted for: doses awarded to your practice that cannot be located and have not been recorded as wasted or administered
Returned: unexpired, viable doses your practice did not use and has given back to SFDPH
Remaining doses: doses still in your inventory
1. Total usage by formulation and source:
STANDARD FLU VACCINE
(MULTI-DOSE VIALS)
PRESERVATIVE FREE VACCINE
(PRE-FILLED SYRINGES)
State Federal State Federal
Awarded
Administered
Wasted
Unaccounted for
* Please explain below
Returned
Remaining doses
Please continue to next page for age group break down.
Organization Name: _____________________________________________________________________________________
Complete and Return to immunization.dph@sfdph.org by Friday, January 22, 2021
SFDPH Communicable Disease Prevention Unit 101 Grove Street, Room 406 San Francisco CA 94102
2. Administration breakdown by age group:
STANDARD FLU VACCINE (MULTI-DOSE VIALS)
Source 6-35 mos 3-6 yrs 7-18 yrs 19-49 yrs 50-59 yrs 60-64 yrs 65+ yrs
State
Federal
PRESERVATIVE FREE VACCINE (PRE-FILLED SYRINGES)
Source 6-35 mos 3-6 yrs 7-18 yrs 19-49 yrs 50-59 yrs 60-64 yrs 65+ yrs
State
Federal
3. Fee your organization charged for administering each flu shot:__________________________
4. Total number of flu vaccine doses that your organization administered from
sources other than SFDPH (includes VFC and privately purchased vaccines): ______________
5. If your organization held flu clinics for the general public, total number of
shots you admininstered to individuals who were not already your patients: _________________
Please use this space to explain wasted flu vaccine doses.___________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Please use this space to explain unaccounted flu vaccine doses.______________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Please offer your comments regarding flu vaccine distribution and usage this season:____________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Person completing report:
Name Title
SIGNATURE Date
Phone # Fax # Email
Thank You!
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STATEFEDERAL INFLUENZA VACCINE, MID YEAR USAGE REPORT, 2020-21 (Disease Prevention & Control - San Francisco Department of Public Health)

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Completed 10 January 2021

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