Medical Services
●
Disease Control
Non-Viable Vaccine Return and Wastage Form
Provider
Provider ID Number:
Provider Name:
Contact Person:
Telephone Number:
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?
Yes
No
Return Code
Vaccine
Doses
Manufacturer
Lot Number
Expiration Date
Expired
Refrigerator/freezer failure
Power failure
Refrigerator/freezer unplugged
Failure to store properly upon receipt
Unusable upon delivery
Other
Reason
DTaP
DTap/HepB/IPV
DTap-IPV
DTap-IPV/Hib
Hep A/Hep B
Hepatitis A
Hepatitis B
HIB
HPV
Influenza
IPV
Meningococcal Conjugate (MCV)
MMR
Other
Pneumococcal Conjugate (PCV)
Pneumococcal Polysaccharide (PPV)
Rotavirus
Td
Tdap
Varicella
Zoster
GlaxoSmithKline
Merck
Sanofipasteur
Massachusetts Biologicals
Novartis
Wyeth
MedImmune
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