Nevada State Immunization Program Temperature Log

Form 4

Nevada State Immunization Program Temperature Log

Temp Log

Instructions: If the temperature recorded is in the shaded zone: 1.Store the vaccine under proper conditions as quickly as possible, 2. Call Glenn Witt, at the Immunization Program at (775) 684-5900 for instructions, 3. Call the vaccine manufacturer(s) to

determine whether the viability of the vaccine(s) has been affected, and 4. Document the action taken on the Vaccine Incident Report and fax the form to (775) 684-8338.

Month/Year Reported:

Facility Name:

PIN #:

Day of Month:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Time of day:

AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM

Temp F°

Temp C°

PLEASE FAX WITH YOUR VACCINE REQUEST

Refrigerator Temp

≥ 49

≥ 9.5

48

9.0

Take immediate action if temperature falls in the shaded area

47

8.5

46

8.0

45

7.5

44

7.0

43

6.5

42

6.0

41

5.5

40

5.0

39

4.5

38

4.0

37

3.5

36

3.0

35

2.0

34

1.5

33

0.5

32

0.0

31

-0.5

Take immediate action if temperature falls in the shaded area

30

-1.0

29

-1.5

≤ 28

≤ -2.0

Freezer Temp

≥ 8

≥ -13

7

-14.0

Take immediate action if temperature falls in the shaded area

6

-14.5

5

-15.0

4

-15.5

≤ 3

≤ -16

or colder

Room Temp

Staff Initials

NOTE: ONLY mark temperatures for the days your facility is open - DO NOT cross out weekends or holidays.

Has this facility's vaccine contact changed: Y / N (If yes, please submit a Provider Information Change Form)

Thermometer Exp Date______________

Page 4 of 4

February 2014 Revision