Non-Viable Vaccine Return and Wastage Form

Provider
Provider ID Number:  Provider Name: 
Contact Person:  Telephone Number: 
Fax NumberEmail Address
  1. Complete this form and submit. Please keep a copy of the confirmation page for your records.
  2. Prior to returning unopened, non-viable vaccine, you must have a packing slip from the NDDoH AND a shipping label from McKesson.
  3. Ship unopened, non-viable vaccine and a copy of the packing slip in a shipping container received from previous vaccine shipments.
  4. 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. Open vials/syringes must never be returned to McKesson.


Reminders:
  • DO NOT contact UPS or McKesson directly to arrange for a pick up.
  • DO NOT ship viable vaccine to McKesson.
  • DO NOT ship viable or non-viable vaccine to the NDDoH
  • DO NOT ship privately-purchased vaccine to McKesson. Only state-supplied vaccine should be returned to McKesson.

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

Return CodeVaccineDosesManufacturerLot NumberExpiration Date

Reason  

Presentation  

 
      


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