EMERGENCY RESPONSE PLAN (Sample)
Post on outside of refrigerator for all staff

Practice Name: | | |
Primary Person Responsible: | | Phone: |
Secondary Person Responsible: | | Phone: |
Person with 24-hour access: | | Phone: |

For a Power Outage: If you do not have a generator, identify at least one location with a generator (hospital, 24-hour store, etc.). Before transporting, call the back-up location site to ensure that their generator is working.

#1.Location & Contact’s Name	Ph# _________________________________
#2.Location & Contact’s Name	Ph#__________________________________

How will you be notified of an outage?	

Vaccines must be transported in an insulated cooler with a barrier separating the vaccines from the ice/cold packs.   
Varicella, MMRV and zoster must be transported with dry ice.
Location where dry ice may be purchased	Ph#	

If your emergency back-up location is more than 30 minutes away and you have a large quantity of vaccine, consider renting a refrigerated truck to transport your vaccine.
Refrigeration Company	Ph#	

OTHER RESOURCES:
Local Health Department:	Ph#_________________	

PREVENT LOSS FROM EXPIRED VACCINES!!

Check and rotate your stock to assure shortest dated vaccine is  used first.  (Post vaccine expiration date table.)  
Notify the state Immunization Program if vaccines are going to expire within 3-6 months.

CHECK AND RECORD REFRIGERATOR AND FREEZER TEMPERATURES TWICE A DAY
•	Once in the am when the practice opens.
•	Once in the afternoon to allow for adjustments prior to the time the practice closes.

What to do if a power failure occurs, the refrigerator door was left open, the temperature was too cold, the refrigerator plug was pulled, or any other situation which would cause improper storage conditions:

1.	Close the door and/or plug in the refrigerator/freezer.
2.	Record the current temperature of the refrigerator/freezer.
3.	Store the vaccines at appropriate temperatures. Make sure that the refrigerator/freezer is working properly or move the vaccines to a unit that is. Do not automatically throw out the affected vaccine.  Mark the vaccine so that the potentially compromised vaccines can be easily identified.
4.	Collect essential data on the reverse side of this sheet and notify the state health department.
5.	Call all manufacturers of affected vaccine(s) (see table on the backside).

Turn over for Emergency Response Worksheet

EMERGENCY RESPONSE WORKSHEET
1.	Current temperature of refrigerator:			Max/min temperature reached:		
2.	Current temperature of freezer:			Max/min temperature reached:		
3.	Amount of time temperature was outside normal range:	refrigerator			freezer:		
Refrigerator
Vaccine and Lot # | Expiration Date | Amount of Vaccine
Freezer
Vaccine and Lot # | Expiration Date | Amount of Vaccine

CALL ALL MANUFACTURER(S) OF AFFECTED VACCINE(S):

Manufacturer | Telephone Number
Sanofi Pasteur | 1-800-822-2463
Merck | 1-800-609-4618
GlaxoSmithKline | 1-888-825-5249
Wyeth | 1-800-999-9384
Novartis | 1-800-244-7668
MedImmune | 1-877-633-4411