Vfc Vaccine Borrowing Report Form - New York City Department Of Health And Mental Hygiene

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

Mary T. Bassett, MD, MPH

Commissioner

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Bureau of Immunization, 42-09 28

th

St., LIC, NY 11101

Tel. 347-396-2404 Fax: 347-396-2559 Email: nycimmunize@health.nyc.gov

VFC Vaccine Borrowing Report

Guidance:

Borrowing of vaccines should only occur in rare occasions when there is a lack of appropriate stock vaccine due to unexpected circumstances such as the vaccine is about

to expire or shipment delays due to vaccine unavailability or vaccine shortages. VFC-enrolled providers are always expected to maintain an adequate inventory of vaccine for

both their VFC and non-VFC-eligible patients and vaccine borrowing should not change this expectation. VFC vaccine cannot be used as a replacement system for a provider’s

privately purchased vaccine inventory unless the vaccine is about to expire and you want to avoid vaccine wastage. The provider must assure that borrowing VFC vaccine will not

prevent a VFC-eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible child.

Directions for use of this form:

When a provider borrows vaccine from one stock to administer to a child who is eligible to receive vaccine from the other stock, each vaccine borrowing occurrence must be

listed on a separate row (vaccine borrowed, lot#, patient name, DOB, and date borrowed). As soon as the borrowed vaccine doses are replaced, the name of the child that

received the vaccine, date of administration, and lot# must also be entered. These borrowing reports must be kept for at least three years and be available during the VFC site visit.

Vaccine

Lot#

Patient Name

DOB

Date

Reason no appropriate stock vaccine

Patient Name

Date Vaccine

Lot#

Borrowed

Insurance status:

Borrowed

was available

Insurance status:

Returned by

(VFC or private)

(circle one)

(VFC or private)

Administration

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

1.No private stock – reason:_______________________

2.No VFC stock – reason:_________________________

3. other (specify):________________________________

"I hereby certify, subject to penalty under the False Claims Act (31 U.S.C. § 3730) and other applicable Federal and state law, that VFC vaccine dose borrowing and replacement reported

on this form has been accurately reported and conducted in conformance with VFC provisions for such borrowing and further certify that all VFC doses borrowed during the noted time

period have been fully reported on this form.”

Provider Pin#:________________ Provider Name:

________

Provider Signature:

___________

Date:_____________

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