Revised 615 take action document Are Temps in Range YesNoTime AMStaff InitialsStaff InitialsActual TemperatureAre Temps in Range YesNoAre Temps in Range YesNoTime AMTime PMStaff ID: 470232
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RESET MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICESBUREAU OF IMMUNIZATIONSVACCINES FOR CHILDREN PROGRAM TEMPERATURE LOG CELSIUS (C) 930 Wildwood DriveJefferson City, MO 65109 800.219.3224 FAX: 573.526.5220 CLINIC NAME: VFC PIN: __________________________ Temperature Logs are due the fi rst business day of each month. Document temperatures twice daily.Trained staff shall record:time, refrigerator and freezer AM and PM temperatures, refrigerator and freezer minimum/maximum temperatures since previous reading, initials and indicate if temperatures are in range by “Y” or “N”. REFRIGERATOR (Temperature Range not less than 2to 8C) (Optimum Temperature 4 FREEZER (Temperature Range is -15 C) If temperatures are NOT in range T AKE A CTION , C ONTACT the VFC P rogram MMEDIATELY and D OCUMENT the ACTION TAKEN . Day of MonthTime: AMRefrigerator AMTemperature Freezer AM Temperature RefrigeratorMin/MaxTemperatureFreezerMin/MaxTemperatureStaff Initials Time: Refrigerator TemperatureFreezer PM TemperatureStaff InitialsTemperatures In Range(Y/N) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Action Taken: MO 58072 (4-17)Rev 4- pages, if needed.) MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICESBUREAU OF IMMUNIZATIONSVACCINES FOR CHILDREN PROGRAM TEMPERATURE LOG CELSIUS (C) 930 Wildwood DriveJefferson City, MO 65109 800.219.3224 FAX: 573.526.5220 CLINIC NAME: VFC PIN: __________________________ Temperature Logs are due the fi rst business day of each month. Document temperatures twice daily.Trained staff shall record:time, refrigerator and freezer AM and PM temperatures, refrigerator and freezer minimum/maximum temperatures since previous reading, initials and indicate if temperatures are in range by “Y” or “N”. (TemperaturOptimummperature FREEZER (Temperature Range is -15 C) If temperatures are NOT in range T AKE A CTION , C ONTACT the VFC P rogram I MMEDIATELY and D OCUMENT the ACTION TAKEN . Day of MonthTime: AMRefrigerator AMTemperature Freezer AM Temperature RefrigeratorMin/MaxTemperatureFreezerMin/MaxTemperatureStaff Initials Time: Refrigerator TemperatureFreezer PM TemperatureStaff InitialsTemperatures In Range(Y/N) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Action Taken: MO 58072 (4-17)Rev 4- pages, if needed.)