Download 'Cold chain failure report' (PDF document)
Name and position of person reporting:___________________________________________
District/region/country: ______________________________________________________________
Incident date and location (central pharmacy, transport, vaccination centre etc.): _____________________________________________________
Type and model of equipment (refrigerator, vaccine carrier, RCW25 etc.): ____________________________________________________________
Monitoring device aCitation a.If monitoring with a Log Tag® , attach data. (thermometer, Log Tag®, Freeze-tag®) and recorded readings ___________________________________________
Incident summary (circumstances, source of the problem, temperature noted, times, etc.) and look for probably causes:
|
Actions taken to fix the problem:
List of products and information:
| Item code | ||||
| Item | ||||
| Manufacturer | ||||
| Lot no. | ||||
| Expiry date | ||||
| Quantity | ||||
| Price/unit | ||||
| Total value | ||||
| VVM status | ||||
| Has the product already been exposed to a breach of cold chain before this incident? |
- (a)
If monitoring with a Log Tag® , attach data.