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:____________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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