CONFIDENTIAL 
                   
                  This document contains information that is confidential in nature and must be maintained in strict 
                  confidence. Recipients of this document shall not use or disclose the information contained in this 
                  document for any purpose other than for the authorised activities under COVID-19 vaccine national 
                  roll-out strategy. 
                   
                  COVID-19 Vaccine Roll-out 
                  Australian Government COVID-19 Vaccine Stock Management 
                  Form 
                  This ‘Vaccine Stock Management Form’ should be completed at the end of each day during the period that 
                  COVID-19 vaccine is held at the location to which the vaccine is delivered (Site) and then sent to 
                  COVID19VaccineStock@health.gov.au by no later than 9pm each day (local time at the Site).   
                  It is critical that cold-chain storage and handling requirements for the vaccine are maintained at all times and 
                  are not breached during the stocktake process. This means that: 
                                                                 o     o
                  •       the AZ vaccine must be maintained at 2 C to 8 C 
                  •       the Pfizer vaccine must be maintained at:  
                                      o        o
                          •        -60 C to -90 C (if the Pfizer vaccine is frozen); 
                                    o      o
                          •        2 C to 8 C (if the Pfizer vaccine has been thawed). 
                  If the Site holds more than one type of COVID-19 vaccine, a separate form must be completed for each 
                  vaccine. 
                   Details  
                   Vaccine                                        [Insert AZ vaccine or Pfizer vaccine] 
                   Site ID (if applicable):                        
                   Name of Site:                                   
                   Address of Site:                                
                   Date of Vaccine Stock Management Form:          
                   Name of authorised contact person at Site:      
                   Contact details of authorised contract          
                   person at Site  
                   (Email address and phone number): 
                   Location(s) of administration of vaccines       
                   (insert “This Site only” or add the name and 
                   address of any other vaccine administration 
                   location(s)) 
                   
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                  CONFIDENTIAL 
                   
                  This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients 
                  of this document shall not use or disclose the information contained in this document for any purpose other than for the 
                  authorised activities under COVID-19 vaccine national roll-out strategy. 
                   
                  STOCK SUMMARY 
                    Required Information                            # Vials     # Doses      Comments  
                                                                                             (Identify any issues) 
                    *Usable stock on hand at the start of the                                 
                    day 
                    *Note: do not include any stock held in quarantine due 
                    to issues identified at delivery or for any other reason. 
                    Number of doses and vials of vaccine                                      
                    administered to patients during the day 
                    Number of doses and vials transferred TO                                 Details of location(s) TO which the vaccines 
                    other location(s) during the day                                         were transferred:  
                                                                                              
                    Number of doses and vials transferred                                    Details of location(s) FROM which the 
                    FROM other location(s) during the day                                    vaccines were transferred:  
                                                                                              
                    Usable stock on hand at end of current day                                
                   
                                                       
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                   CONFIDENTIAL 
                    
                   This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients 
                   of this document shall not use or disclose the information contained in this document for any purpose other than for the 
                   authorised activities under COVID-19 vaccine national roll-out strategy. 
                    
                   Summary of Wastage  
                   Please complete this section to provide Health with details of all wastage that may have occurred during the 
                   day.  
                   Where a potential wastage incident or an actual wastage incident (e.g. damaged vials, breach of cold chain 
                   requirements) involves 5 or more vials at one time, you must notify Health immediately by calling the Vaccine 
                   Operations Centre on 1800 318 208 and by emailing Health, and include a detailed Vaccine Wastage Report 
                   (the separate form) in your email, to COVID19VaccineWastage@health.gov.au.   
                   In addition, all wastage for the day must be reported using the table below.  An explanation of the specific 
                   details as to how wastage occurred should be provided by completing the right-hand column. 
                     Summary of Wastage                       Yes/No        # vials     # doses     Details of how wastage occurred and 
                                                                           wasted       wasted      any other comments 
                     1.  Was there a wastage incident         Yes/No                                 
                         during the day over the 
                         threshold (5 or more vials)?   
                     2.  If yes to Q1, did you report         Yes/No                                 
                         the incident immediately to 
                         Health?  
                     3.  Was there wastage below the          Yes/No                                 
                         threshold during the day?  
                     4.  What was the total volume of wastage                                        
                         during the day? 
                    
                                                          
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                                CONFIDENTIAL 
                                 
                                This document contains information that is confidential in nature and must be maintained in strict confidence. Recipients 
                                of this document shall not use or disclose the information contained in this document for any purpose other than for the 
                                authorised activities under COVID-19 vaccine national roll-out strategy. 
                                 
                                 
                                Signature 
                                 
                                 
                                 
                                 
                                 
                                   Completed by: _________________                                           Position: _________________                                              Signature: ___________________ 
                                                                                                                                                                                      Date:          __________________ 
                                   Checked by: _________________                                             Position: _________________                                              Signature: ___________________ 
                                                                                                                                                                                       Date:         ___________________ 
                                 
                                Note: giving false or misleading information to the Commonwealth is a criminal offence. 
                                 
                                 
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