Form Doh 348-077 - Vaccine Storage Refrigerator Temperature Monitoring Log
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4REFRIGERATOR TEMPERATURE MONITORING LOG: Days 1-15
CLINIC NAME:_____________________________
PROVIDER PIN:____________________
F° C°
FRIDGE NAME/NUMBER:____________________
MONTH/YEAR:_____________________
0.
0.
RECORDING TEMPERATURES:
IF A TEMPERATURE RECORDING IS IN THE SHADED ZONE:
1.
Circle if you are recording in C° or F° on the temperature log.
1.
Store the vaccine under proper conditions as quickly as possible. Place the affected vaccine in a
2.
2a.
Record min/max temps preferably at the start of clinic hours.
bag and mark the vaccine as "Do not use."
3.
Record storage unit temperatures twice a day.
2.
Call the vaccine manufacturers to determine whether the vaccines are viabile.
4.
Place an 'X' or record the temperature in the box that corresponds with the temperature range.
3.
Contact your local health jurisdiction for further assistance: (_____) _____________
4.
Use the Changes tracking area to record the actions taken to correct the problem.
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Day of Month
Min/Max Temp
Refrigerator
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
Exact Time of
Temp
Room Temp
Staff Initials
≥
49°F (9.5°C)
48°F (8.9°C)
47°F (8.4°C)
46°F (7.8°C)
45°F (7.3°C)
44°F (6.8°C)
43°F (6.2°C)
42°F (5.5°C)
41°F (5.0°C)
40°F (4.5°C)
39°F (3.9°C)
38°F (3.4°C)
37°F (2.7°C)
36°F (2.3°C)
35°F (1.7°C)
34°F (1.1°C)
33°F (0.6°C)
≤32°F (0.0°C)
DATE
°F /°C
Action Taken: Fridge control adjusted, called
Please list any steps
you've taken to address
1/1
33.1 °F
LHJ, etc.
temperature or storage
unit issues
If you have a disability and need this document in a different format, please call 1-800-525-0127 (TDD/TTY 711).
DOH 348-077 July 2016
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Parent category: Miscellaneous