Non-Viable Vaccine Return and Wastage Form

Provider
Provider ID Number:	Provider Name:
Contact Person:	Telephone Number:
Fax Number	Email Address
Complete this form before returning unopened, non-viable vaccine. Print two copies of the confirmation page, one for your records and one for McKesson Ship unopened non-viable vaccine and a copy of the confirmation page to McKesson in a shipping container received from previous vaccine shipments. Open vials, including multi-dose vials, or open pre-filled syringes, cannot be sent to McKesson. For vaccine in open vials/syringes, use this form to report the wasted/expired vaccine, and then dispose of it per your facility’s policy. Check here to have a McKesson return label sent to you in the mail. Do not contact UPS or McKesson directly to arrange for a pick up. Send the shipment with a UPS driver. DO NOT ship viable vaccine to McKesson. DO NOT ship viable or non-viable vaccine to the NDDoH.

Has this return/wastage been entered in NDIIS (THOR) by your facility? YesNo

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