Are you reporting Monkeypox vaccine wastage or redistribution?
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Wastage
Redistribution
Expectations for Vaccine Redistribution:
You must complete documentation each time vaccine is redistributed. Transfer Monkeypox vaccine at 2⁰ to 8⁰C (36⁰ to 46⁰F) (a refrigerated temperature) unless otherwise approved by MDH. Upon receiving vaccine, immediately put the vaccine in the refrigerator at 2⁰ to 8⁰C (36⁰ to 46⁰F) and monitor it using a continuous temperature monitoring device. Monitor vaccine temperature during transit using a continuous temperature monitoring device in the transport cooler. Only full, sealed vials can be transferred. Name of Site Redistributing Vaccine:
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Allina Health Bandana Square Clinic ALLINA HEALTH UPTOWN CLINIC Avera Medical Group Worthington Beltrami County Public Health Boynton Health CentraCare Clinic-Obstetrics and Gynecology CentraCare Family Health Center Children's Minnesota (Children's Hospital and Clinics - Minneapolis Hospital) Clinic 555 Dakota County Public Health Essentia Health- Moorhead Clinic Essentia Health St. Mary's Duluth Face to Face Gundersen Lutheran Medical Center Winona Campus HealthPartners HealthPartners Bloomington Hennepin Healthcare Infectious Disease Clinic HHS Pharmacy HHS Public Safety/Jail HHS Whittier Clinic Indian Health Board of Minneapolis La Clinica M Health Fairview Delaware Street Clinic M Health Fairview Health & Wellness Hub - Center for Community Health Equity Mayo Clinic MN Community Care - Downtown Clinic Native American Community Clinic North Memorial Health Hospital Northpoint Health and Wellness Center Olmsted County Public Health Park Nicollet Clinics 3800 St. Louis Park Clinic - Infectious Disease Park Nicollet St. Louis Park 3850 Red Door Clinic Sanford Bemidji Medical Center Sanford Worthington Medical Center St. Louis County Public Health St. Luke's Infectious Disease Stillwater Medical Group Curve Crest The Aliveness Project United Family Medicine Winona County Health and Human Services Winona Health Services Other
Start typing the name of your location. If your location does not appear, please select "other" and email health.mdhvaccine@state.mn.us to be added to this list
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Street Address 1
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State
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Zip Code
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Point of Contact Email
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Name of Site Receiving Vaccine:
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Allina Health Bandana Square Clinic ALLINA HEALTH UPTOWN CLINIC Avera Medical Group Worthington Beltrami County Public Health Boynton Health CentraCare Clinic-Obstetrics and Gynecology CentraCare Family Health Center Children's Minnesota (Children's Hospital and Clinics - Minneapolis Hospital) Clinic 555 Dakota County Public Health Essentia Health- Moorhead Clinic Essentia Health St. Mary's Duluth Face to Face Gundersen Lutheran Medical Center Winona Campus HealthPartners HealthPartners Bloomington Hennepin Healthcare Infectious Disease Clinic HHS Pharmacy HHS Public Safety/Jail HHS Whittier Clinic Indian Health Board of Minneapolis La Clinica M Health Fairview Delaware Street Clinic M Health Fairview Health & Wellness Hub - Center for Community Health Equity Mayo Clinic MN Community Care - Downtown Clinic Native American Community Clinic North Memorial Health Hospital Northpoint Health and Wellness Center Olmsted County Public Health Park Nicollet Clinics 3800 St. Louis Park Clinic - Infectious Disease Park Nicollet St. Louis Park 3850 Red Door Clinic Sanford Bemidji Medical Center Sanford Worthington Medical Center St. Louis County Public Health St. Luke's Infectious Disease Stillwater Medical Group Curve Crest The Aliveness Project United Family Medicine Winona County Health and Human Services Winona Health Services Other
Begin typing to find the name of the facility receiving vaccine. If the site is not listed, select "other" and email health.mdhvaccine@state.mn.us to add your site to the list
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Street Address 1
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State
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Zip Code
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Point of Contact Email
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Date of Redistribution:
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Today Y-M-D
Physical Redistribution: redistribution to store vaccine at receiving site
Ownership Redistribution: transfer of ownership from site storing vaccine to site that is responsible for vaccinating. In this case, the vaccine is NOT physically being transferred from one facility to another.
Both Physical and Ownership Redistribution
Note: Do not report redistribution twice for the same set of doses if both physical and ownership redistribution apply.
Vaccine Type:
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Jynneos
If you are redistributing more than one vaccine product you must complete another redistribution form.
Lot Number:
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Today M-D-Y
Number of Vials:
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Enter 0 if not applicable
I attest that temperatures are monitored while in transport and any temperature excursions are reported to manufacturer.
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Yes
No
Yes
No
Name of Site Wasting Vaccine:
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Allina Health Uptown Clinic Allina Health Bandana Square Clinic Beltrami County Family Health Clinic Boynton Health CentraCare Family Health Center CentraCare Obstetrics & Gynecology Dakota County Public Health Delaware Street Clinic at Fairview CSC Essentia Health Duluth HealthPartners - Bloomington HealthPartners - Methodist Hospital HealthPartners Olivia Hospital & Clinic HealthPartners - Regions Hospital HealthPartners Warehouse Hennepin Healthcare Infectious Disease Clinic / Positive Care Clinic Hennepin Healthcare Pharmacy Hennepin Healthcare Public Safety/County Jail Hennepin Healthcare Whittier Clinic Indian Health Board of Minneapolis La Clinica Mayo Clinic Rochester Hospital Minneapolis - Veterans Affairs Minnesota Community Care - Healthcare for the Homeless Downtown Clinic Minnesota Public Health Laboratory Native American Community Clinic North Memorial Health Care Hospital NorthPoint Health & Wellness Center Northern Lights Pediatrics Park Nicollet - St Louis Park 3850 Park Nicollet 3800 Red Door Clinic Sanford Bemidji Main Clinic Family Medicine Sanford East Grand Forks Sanford Worthington Medical Center St. Louis County Public Health St. Luke's Infectious Disease and Travel Medicine St. Paul Ramsey County Public Health / Clinic 555 Stillwater Medical Curve Crest The Aliveness Project United Family Medicine Winona County Community Services Winona Health Services Other
Start typing the name of your location. If your location does not appear, please select "other" and email health.mdhvaccine@state.mn.us to be added to this list
Federal PIN of Site Wasting Vaccine:
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Start typing the name of your location. If your location does not appear, please select "other" and email health.mdhvaccine@state.mn.us to be added to this list
Street Address 1
* must provide value
State
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Zip Code
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Point of Contact Email
* must provide value
Date of Wastage:
* must provide value
Today M-D-Y
Vaccine Type:
* must provide value
Jynneos
If you are redistributing more than one vaccine product you must complete another redistribution form.
How is your site currently administering doses?
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Subcutaneous Administration
Intradermal Administration
Lot Number:
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Today M-D-Y
Number of Vials Wasted:
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Please only report entire vials that were wasted. If at least 1 dose was administered from the vial, it is not considered a wasted vial.
Expired Product
Damage Product
Temperature Excursion
Other
Please Explain:
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condensed as possible
Confirmation Vaccine was Destroyed on Site
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Confirmed
Timestamp:
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Now M-D-Y H:M
Yes
No