Vaccine Return / Wastage Form

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NON-USEABLE VACCINE RETURN FORM

"*" indicates required fields

To: Haldimand-Norfolk Heath Unit-Vaccine Preventable Disease Team
YYYY slash MM slash DD
List Vaccines*
Vaccine
Lot Number
# of Doses
Reason for Return (see codes below)
 
RETURN CODES:
CCE – Cold Chain Incident-Emergency/Natural Disaster EX – Expired Product
CCH – Cold Chain Incident-Human Error DI – Discontinued Product
CCM – Cold Chain Incident-Malfunction:Fridge/Freezer/Equip. DP – Damaged Product
CCP – Cold Chain Incident-Power Outage FC – Facility Closure
CCT – Cold Chain Incident-Temperature Breached in Transit RP – Recalled Product
DE – Defective Product SV – Suspected Vaccine Contamination
Please ensure all boxes are filled out for each vaccine recorded for returns. All returns must be packaged together with this
form securely attached. If you have any questions, please feel free to contact the Health Unit at 519-426-6170.
Simcoe: P.O. Box 247, 12 Gilbertson Drive, Simcoe, ON N3Y 4L1 Phone: 519.426.6170 or 905.318.6623
Caledonia: 282 Argyle Street South, Caledonia, ON N3W 1K7 Phone: 905.318.6623