Adverse Storage Condition Report Internal Form Search Submit Search Print this Page Home » For Professionals » Vaccine Ordering & Guidance » Annual Fridge Inspection » Adverse Storage Condition Report Internal Form This form is for Health Unit staff. Please Select Your Holding Point Number - see yellow sticker on vaccine fridge(Required)***Please select your Holding Point Number***LGL_BR_00011 - AlmonteLGL_BR_00004 - BrockvillleLGL_BR_00001 - Brockville Fridge 1 INVENTORYLGL_BR_00002 - Brockville Fridge 2 INVENTORYLGL_BR_00003 - Brockville Fridge 3 INVENTORYLGL_BR_00008 - Brockville Fridge 8 RABIESLGL_BR_VPD_OP_0001 - 80 FreezerLGL_BR_00009 - KemptvilleLGL_BR_00012 - GananoqueLGL_BR_00007 - Smiths FallsLGL_BR_00131 - Schools - NorthLGL_BR_00005 - Schools - SouthIf you don’t see your holding point location in the list, please email [email protected]Date Report Completed (yyyy/mm/dd)(Required)Report Completed By(Required) First Name Last Name Telephone Number(Required)ExtensionEmail 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 ExtensionFacility Contact Email Address(Required) Premises Type(Required) Public Health Unit 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 RSV Vaccine/mAB Rabies Publically Funded Vaccine School Vaccine Payable Influenza (Flu) Vaccine Trivalent Vaccine High Dose Trivalent Vaccine COVID-19 Vaccine Pfizer-BioNTech Corminarty Moderna Spikevax RSV Vaccine/mAB Abreyvso Beyfortus Arexvy Rabies Vaccine Immune Globulin Publically Funded Vaccine Act-Hib® Adacel® Adacel® -Polio Bexsero® Boostrix® Boostrix® -Polio Engerix B® Adolescent/Adult Engerix B® Pediatric Engerix B® Dialysis Gardasil® 9 Havrix® Adult Havrix® Pediatric Imovax® Polio Imovax® Rabies Menactra® Menjugate® Menveo® Nimenrix® MMR® II NeisVac-C® Pediacel® Pentacel Pneumovax® 20 Prevnar® 15 Priorix® Priorix-Tetra™ ProQuad® Recombivax HB® Adolescent/Adult Recombivax HB® Pediatric Recombivax HB® Renal Rotarix® Shingrix® Td Adsorbed Td Polio Tubersol® Vaqta Adult Vaqta Pediatric Varilix® Varivax® III Other Vaccine Not Listed School Vaccine(Required) Men C - ACYW135 Hep B Hep B pediatric HPV 9 Epinephrine Payable(Required) HPV 9 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®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 VaccinesEngerix B® DialysisNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysGardasil® 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® VaccinesPentacelNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysPentacel Total Number of DosesPneumovax® 20Number 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® 20 Total Number of DosesValue of Returned Pneumovax® VaccinesPrevnar® 15Number 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® 15 Total Number of DosesValue of Returned Prevnar® 15 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® 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® VaccinesVaqta AdultNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysVaqya PediatricNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysVarilix®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 VaccinesTrivalent VaccineNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysTrivalent Total Number of DosesHigh Dose Trivalent VaccineNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHigh Dose Trivalent Total Number of DosesMen C - ACYW135Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysMen C - ACYW135 Total Number of DosesHep BNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHep B Total Number of DosesHep B pediatricNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHep B pediatric Total Number of DosesHPV 9Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHPV 9 Total Number of DosesEpinephrineNumber of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysEpinephrine Total Number of DosesHPV 9Number of DosesLot NumberExpiry Date (yyyy/mm/dd)Previous Exposure (Yes/No) Add RemovePlease provide Number of Doses, Lot Number, Expiry Date (yyyy/mm/dd), and Previous Exposure (Yes/No) to avoid any delaysHPV Total Number of DosesPfizer-BioNTech CorminartyNumber 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 SpikevaxNumber 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 delaysAbreyvsoNumber 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 delaysBeyfortusNumber 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 delaysArexvyNumber 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 delaysRabies VaccineNumber 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 delaysImmune GlobulinNumber 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 VaccinesThis field is hidden when viewing the formHealth Unit Use OnlyThis field is hidden when viewing the formClient IDThis field is hidden when viewing the formMost Recent Fridge Inspection Date (yyyy/mm/dd)This field is hidden when viewing the formDetected on Annual Fridge InspectionThis field is hidden when viewing the formDate Public Health Unit Notified (yyyy/mm/dd)This field is hidden when viewing the formHolding Point NumberThis field is hidden when viewing the formFridge NumberThis field is hidden when viewing the formASC Number for PanoramaThis field is hidden when viewing the formStaff Member Who Initiated ASCThis field is hidden when viewing the formComments (MFR Reference Numbers If Info is Pending from MFR)CAPTCHA