2017 MnVFC Site Visit Storage & Handling Per Unit Answer Sheet
MnVFC PIN: ___________________
Question number and
content area
Unit description – Brand:
Location:
4.1A Type of unit
Stand-alone
Combination
4.1B Use if stand-alone
Refrigerator
Freezer
4.1B Use if combination
Both sections
Refrigerator only
4.2
Pharmaceutical
Commercial/household
Select grade
Freezer only
[O] CDC does not
recommend using both
sections of household units
Temperature Monitoring Device Questions: Questions 4.3-4.7 must be answered separately for the freezer and
refrigerator if the unit is a combo. Be sure to document responses in the appropriate column.
Storage unit section
Refrigerator
Freezer
4.3A Temperature monitoring device
Yes
No [X] (if no, skip to 4.7)
Yes
No [X] (if no, skip to 4.7)
4.4A Continuous monitoring and
recording device
Yes
No [O] (if no, skip D)
Yes
No [O] (if no, skip D)
4.4B Have a probe in buffered
material
Yes
No [O]
Yes
No [O]
4.4C Digital display that can be read
from outside the unit
Yes
No [O]
Yes
No [O]
4.4D Data downloaded and reviewed
routinely (e.g., weekly)
Yes
No [O]
Yes
No [O]
4.5A Certificate of Calibration Testing
Yes
No [X]
Yes
No [X]
[X] Follow-up is required if expired
[X] Follow-up is required if expired
4.5D Certificate contains all necessary
items
Yes
No [X]
Yes
No [X]
4.6
Yes
No [X]
Yes
No [X]
4.7A Two temperature readings per
day
Yes
No [X]
Yes
No [X]
4.7B Time, date and name (or initials)
for each reading
Yes
No [X]
Yes
No [X]
4.5B Date of calibration
4.5C Date certificate expires
Probe properly placed
4.7C Current temperature and
min/max temperatures (if
available)
Current: ________°
Minimum: ________°
Maximum: ________°
Fahrenheit
Celsius
Current: ________°
Minimum: ________°
Maximum: ________°
Fahrenheit
Celsius
(February 2017) Page 1 of 2
MNVFC SITE VISIT STORAGE & HANDLING PER UNIT ANSWER SHEET
Question number and
content area
4.7D Maintaining appropriate
temperatures
Unit description – Brand:
Location:
Yes
No [X]
Not enough info [X]
Yes
No [X]
Not enough info [X]
Answer questions 4.8-4.10 for the unit as a whole rather than for individual sections (if a combination unit)
4.8A Vaccines exposed to any out-ofrange temperatures in last 3
months (including today)
Yes
No (if no, skip to question 4.9)
4.8B Quarantine and label vaccines
“do not use”
Yes
No [X]
4.8C Move vaccine to a unit with
proper temps (if applicable)
Yes
No [X]
4.8D Report to the immunization
program
Yes
No [X]
4.8E Manufacturer contacted about
usability of the vaccine
Yes
No [X]
4.9A Vaccines placed in the middle of
the unit with space for air
circulation
Yes
No [O]
4.9B Vaccine stored in original
packaging
Yes
No [O]
4.9C Water bottles in fridge and
frozen water bottles in freezer
Yes
No [O]
4.9D Vaccines stored in doors, bins,
near vents or on floor
Yes [O]
No
4.9E Food stored in unit
Yes [O]
No
4.10 Steps being taken to prevent
units from accidently being
disconnected from the power
supply
A. Do not disconnect labels on plug
B. Warning labels on circuit breakers
C. Hard-wired (built-in) and label on circuit breaker
[X] The response is non-compliant
D. Hospital or large health care system with
if only A, only B, or E is selected.
comprehensive written policy and procedures
E. No acceptable measures for preventing
accidental disconnection from power supply [X]
Notes:
Save each Storage & Handling Per Unit Answer Sheet with the Brand + Location in the file name
(example: Samsung.Room123.doc).
(February 2017) Page 2 of 2