Appendix 4 Department of Health & Human Services Maine Center for Disease Control and Prevention Record of Transportation of Vaccines/Biologicals to a Facility for Emergency Cold Storage Name of Facility ________________________________________________ Location ____________________________________ Date & Time Nurse’s Date & Time Nurse’s Name Of Lot #s Manufacturer Comment # Doses Dropped Signature Returned Signature Vaccine/ Dropped Off Returned Biological Off
Appendix 4 Department of Health & Human Services Maine Center for Disease Control and Prevention Record of Transportation of Vaccines/Biologicals to a Facility for Emergency Cold Storage Name of Facility ________________________________________________ Location ____________________________________ Date & # Doses Dropped Off Time Dropped Off Nurse’s Signature Date & Returned Time Returned Nurse’s Signature Name Of Vaccine/ Biological Lot #s Manufacturer Comment
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