Adverse Storage Condition Report Form Search Submit Search Print this Page Home » For Professionals » Health Care & Dental Professionals » Immunization Resources » Adverse Storage Condition Report Form What is a cold chain break? When you suspect that vaccine has been exposed to temperatures below +2ºC or above +8ºC. Vaccines may become ineffective if the vaccine fridge temperature readings are below +2ºC and/or above +8ºC for any length of time. If these vaccines are administered to a patient, they may cause a localized reaction as well as not provide the protection needed. If you suspect or know you’ve had a cold chain break: Do not use and do not discard any of the exposed vaccines at this time. Place all of the vaccines in a labelled container (or bag), marked with the date and time and “DO NOT USE.” Call the public health unit immediately to report the vaccine exposure. 1-800-660-5853 on voice recognition request “Cold Chain”. We need the following information asap in order to determine if you are still able to use the vaccines, or if they need to be disposed of. Number of vials, lot number and expiration date for all publically funded vaccines in the affected vaccine fridge Recent temperature logs – at least 2 weeks – so we can see patterns of temperatures over time Where is the vaccine now? Back in the fridge, another vaccine fridge? To provide us with this information please fill out this online form below. If you have questions, or need assistance, please contact us at [email protected]. The sooner we receive this information, the sooner we can let you know if your vaccines are still viable and may be used. You may need to cancel appointments for vaccinations as we are not able to immediately replace your vaccine supply. Holding Point Number - see yellow sticker on vaccine fridge(Required) LGL_BR_00### Health Care Provider Location *Please insert your official facility name used by MOHLTC(Required) Date Report Completed (yyyy/mm/dd)(Required) Report Completed By(Required) First Name Last Name Telephone Number(Required)Extension Email Address(Required) Incident LocationFacility Name(Required) Facility Contact(Required) Same as above Different than above Facility Contact Name(Required) First Name Last Name Facility Contact Telephone Number(Required)Facility Contact Telephone Number Extension Facility Contact Email Address(Required) Premises Type(Required) Physician Office (FP solo) Physician Office (Ped solo) Physician Office (FP group) Physician Office (Ped group) Community Health Centre Correctional Facility First Nations Facility Hospital Long-Term Care Home Nursing Agency Occupational Health Public Health Unit Pharmacy Retirement Home School Other Other Premises Type(Required) Do you have more than one fridge?(Required) Yes No Which fridge is affected?(Required) Incident DescriptionDate of last known temperature consistently between +2 degrees Celsius to +8 degrees Celsius (yyyy/mm/dd)(Required) Time of last known temperature consistently between +2 degrees Celsius to +8 degrees Celsius (hh:mm)(Required) Date of Incident (yyyy/mm/dd)(Required) Time of Incident Discovered (hh:mm)(Required) Temperature at Time of Incident(Required)MinimumMaximumCurrentPlease provide Minimum, Maximum and Current TemperatureEstimated Duration of Exposure (hours)(Required) Where is the vaccine located now?(Required) Back in the vaccine fridge, temperatures have stabilized In a different vaccine fridge In the cooler Other Other - Please describe(Required) For multiple incidents please describe the event including date and time of incident(s), temperature at time of incident(s) and estimated duration of exposure(s).Event Information(Required) Power Failure Fridge Malfunction (e.g. sensor, compressor) Equipment Malfunction (e.g. thermometer, alarm) Human Error (e.g. fridge door left open, fridge unplugged) Other (describe) How long was the power disrupted?(Required) What was the cause of the disruption(Required) What time of day was the disruption(Required) Other Event Information(Required) Vaccine InventoryWhich type of vaccine Influenza (Flu) Vaccine COVID-19 Vaccine Publically Funded Vaccine Influenza (Flu) Vaccine Alfuria Tetra Fluad® Flucelvax FluLaval Tetra Fluzone® Quadrivalent HD Fluzone® Quadrivalent COVID-19 Vaccine Pfizer-BioNTech Bivalent Pfizer-BioNTech Pediatric Bivalent Pfizer-BioNTech - Other Moderna Spikevax Bivalent Moderna Spikevax Pediatric Moderna Spikevax - Other Publically Funded Vaccine Act-Hib® Adacel® Adacel® -Polio Bexsero® Boostrix® Boostrix® -Polio Engerix B® Adolescent/Adult Engerix B® Pediatric Gardasil® 9 Havrix® Adult Havrix® Pediatric Imovax® Polio Imovax® Rabies Menactra® Menjugate® Menveo® Nimenrix® MMR® II NeisVac-C® Pediacel® Pneumovax® 23 Prevnar® 13 Priorix® Priorix-Tetra™ ProQuad® RabAvert® Recombivax HB® Adolescent/Adult Recombivax HB® Pediatric Recombivax HB® Renal Rotarix® Shingrix® Td Adsorbed Td Polio Tubersol® Varilix® Varivax® III Other Vaccine Not Listed Act-Hib®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $46.00 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysAct-Hib® Total Number of DosesValue of Returned Act-Hib® VaccinesAdacel®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $38.55 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysAdacel® Total Number of DosesValue of Returned Adacel® VaccinesAdacel® -PolioNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $52.79 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysAdacel® -Polio Total Number of DosesValue of Returned Adacel® -Polio VaccinesBexsero®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $109.64 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysBexsero® Total Number of DosesValue of Returned Bexsero® VaccinesBoostrix®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $30.74 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysBoostrix® Total Number of DosesValue of Returned Boostrix® VaccinesBoostrix® -PolioNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $37.06 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysBoostrix® -Polio Total Number of DosesValue of Returned Boostrix® -Polio VaccinesEngerix B® Adolescent/AdultNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $24.01 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysEngerix B® Adolescent/Adult Total Number of DosesValue of Returned Engerix B® Adolescent/Adult VaccinesEngerix B® PediatricNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $11.39 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysEngerix B® Pediatric Total Number of DosesValue of Returned Engerix B® Pediatric VaccinesGardasil® 9Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $170.87 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysGardasil® 9 Total Number of DosesValue of Returned Gardasil® 9 VaccinesHavrix® AdultNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $49.37 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHavrix® Adult Total Number of DosesValue of Returned Havrix® Adult VaccinesHavrix® PediatricNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $24.68 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHavrix® Pediatric Total Number of DosesValue of Returned Havrix® Pediatric VaccinesImovax® PolioNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $47.00 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysImovax® Polio Total Number of DosesValue of Returned Imovax® Polio VaccinesImovax® RabiesNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $207.65 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysImovax® Rabies Total Number of DosesValue of Returned Imovax® Rabies VaccinesMenactra®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $105.30 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysMenactra® Total Number of DosesValue of Returned Menactra® VaccinesMenjugate®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $36.74 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysMenjugate® Total Number of DosesValue of Returned Menjugate® VaccinesMenveo®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $107.21 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysMenveo® Total Number of DosesValue of Returned Menveo® VaccinesNimenrix®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $99.48 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysNimenrix® Total Number of DosesValue of Returned Nimenrix® VaccinesMMR® IINumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $34.33 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysMMR® II Total Number of DosesValue of Returned MMR® II VaccinesNeisVac-C®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $80.19 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysNeisVac-C® Total Number of DosesValue of Returned NeisVac-C® VaccinesPediacel®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $55.02 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysPediacel® Total Number of DosesValue of Returned Pediacel® VaccinesPneumovax® 23Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $24.97 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysPneumovax® 23 Total Number of DosesValue of Returned Pneumovax® VaccinesPrevnar® 13Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $99.02 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysPrevnar® 13 Total Number of DosesValue of Returned Prevnar® 13 VaccinesPriorix®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $29.32 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysPriorix® Total Number of DosesValue of Returned Priorix® VaccinesPriorix-Tetra™Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $96.70 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysPriorix-Tetra™ Total Number of DosesValue of Returned Priorix-Tetra™ VaccinesProQuad®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $116.17 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysProQuad® Total Number of DosesValue of Returned ProQuad® VaccinesRabAvert®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $181.16 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysRabAvert® Total Number of DosesValue of Returned RabAvert® VaccinesRecombivax HB® Adolescent/AdultNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $22.54 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysRecombivax HB® Adolescent/Adult Total Number of DosesValue of Returned Recombivax HB® Adolescent/Adult VaccinesRecombivax HB® PediatricNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $11.40 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysRecombivax HB® Pediatric Total Number of DosesValue of Returned Recombivax HB® Pediatric VaccinesRecombivax HB® RenalNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $184.80 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysRecombivax HB® Renal Total Number of DosesValue of Returned Recombivax HB® Renal VaccinesRotarix®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $88.16 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysRotarix® Total Number of DosesValue of Returned Rotarix® VaccinesShingrix®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $129.20 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysShingrix® Total Number of DosesValue of Returned Shingrix® VaccinesTd AdsorbedNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $22.56 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysTd Adsorbed Total Number of DosesValue of Returned Td Adsorbed VaccinesTd PolioNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $61.55 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysTd Polio Total Number of DosesValue of Returned Td Polio VaccinesTubersol®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $39.60 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysTubersol® Total Number of DosesValue of Returned Tubersol® VaccinesVarilix®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $61.56 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysVarilix® Total Number of DosesValue of Returned Varilix® VaccinesVarivax® IIINumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $81.85 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysVarivax® III Total Number of DosesValue of Returned Varivax® III VaccinesAlfuria TetraNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $13.75 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysAlfuria Tetra Total Number of DosesValue of Returned Alfuria Tetra VaccinesFluad®Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $13.04 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysFluad® Total Number of DosesValue of Returned Fluad® VaccinesFlucelvaxNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $25.00 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysFlucelvax Total Number of DosesValue of Returned Flucelvax VaccinesFluLaval TetraNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $14.00 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysFluLaval Tetra Total Number of DosesValue of Returned FluLaval Tetra VaccinesFluzone® Quadrivalent HDNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $69.50 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysFluzone® Quadrivalent HD Total Number of DosesValue of Returned Fluzone® Quadrivalent HD VaccinesFluzone® QuadrivalentNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePrice per dose: $6.85 Please provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysFluzone® Quadrivalent Total Number of DosesValue of Returned Fluzone® Quadrivalent VaccinesPfizer-BioNTech BivalentNumber of DosesLot NumberDate Out of Freezer (yyyy/mm/dd) Add RemovePlease provide Number of Doses, Lot Number, and Date Out of Freezer (yyyy/mm/dd) to avoid any delaysPfizer-BioNTech Pediatric BivalentNumber of DosesLot NumberDate Out of Freezer (yyyy/mm/dd) Add RemovePlease provide Number of Doses, Lot Number, and Date Out of Freezer (yyyy/mm/dd) to avoid any delaysPfizer-BioNTech - OtherNumber of DosesLot NumberDate Out of Freezer (yyyy/mm/dd) Add RemovePlease provide Number of Doses, Lot Number, and Date Out of Freezer (yyyy/mm/dd) to avoid any delaysModerna Spikevax BivalentNumber of DosesLot NumberDate Out of Freezer (yyyy/mm/dd) Add RemovePlease provide Number of Doses, Lot Number, and Date Out of Freezer (yyyy/mm/dd) to avoid any delaysModerna Spikevax PediatricNumber of DosesLot NumberDate Out of Freezer (yyyy/mm/dd) Add RemovePlease provide Number of Doses, Lot Number, and Date Out of Freezer (yyyy/mm/dd) to avoid any delaysModerna Spikevax - OtherNumber of DosesLot NumberDate Out of Freezer (yyyy/mm/dd) Add RemovePlease provide Number of Doses, Lot Number, and Date Out of Freezer (yyyy/mm/dd) to avoid any delaysOther Vaccine Not ListedName of VaccineNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Name of Vaccine, Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd) and Previous Exposure (Yes/No) to avoid any delaysTotal Value of all Returned VaccinesHiddenHealth Unit Use OnlyHiddenClient ID HiddenMost Recent Fridge Inspection Date (yyyy/mm/dd) HiddenDetected on Annual Fridge Inspection HiddenDate Public Health Unit Notified (yyyy/mm/dd) HiddenHolding Point Number HiddenFridge Number HiddenASC Number for Panorama HiddenStaff Member Who Initiated ASC HiddenComments (MFR Reference Numbers If Info is Pending from MFR) CAPTCHA