Free Vaccine Celsius Temperature Log Days 1- 31, DPH 42023 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 42023 (10/06)

STATE OF WISCONSIN

VACCINE CELSIUS TEMPERATURE LOG
Days 1 - 15 Refrigerator Location:
Provider Name: Provider Address: REFRIGERATOR Staff Initials Time Day of Month
o

PIN Number: Month/Year:

Contact Name: Contact Phone:

1 am pm am

2 pm am

3 pm am

4 pm am

5 pm am

6 pm am

7 pm am

8 pm am

9 pm am

10 pm am

11 pm am

12 pm am

13 pm am

14 pm am

15 pm

C Temp >11 10 9 8 7 6 5 4 3 2 1 0 <-1

FREEZER >-12 -13 -14 -15 -16 -17 -18 -19 <-20 INSTRUCTIONS: Place an "X" in the box that corresponds with the temperature (rows), day of the month, and am or pm (columns) for your temperature check. Then enter your initials and the time you monitored the temperature in the boxes at the top of the chart. Temperature logs should be maintained for at least three (3) years. * If the temperature is in the gray range: 1. Store the vaccine under proper conditions as quickly as possible, and 2. Call the Division of Public Health, Immunization Program at (608) 267-5148 to determine whether the potency of the vaccines has been affected.

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 42023 (10/06)

STATE OF WISCONSIN

VACCINE CELSIUS TEMPERATURE LOG
Days 16 -31 Refrigerator Location:
Provider Name: Provider Address: PIN Number: Month/Year: Contact Name: Contact Phone:

REFRIGERATOR Staff Initials Time 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day of Month o am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm C Temp >11 10 9 8 7 6 5 4 3 2 1 0 <-1 FREEZER >-12 -13 -14 -15 -16 -17 -18 -19 <-20 INSTRUCTIONS: Place an "X" in the box that corresponds with the temperature (rows), day of the month, and am or pm (columns) for your temperature check. Then enter your initials and the time you monitored the temperature in the boxes at the top of the chart. Temperature logs should be maintained for at least three (3) years. * If the temperature is in the gray range: 1. Store the vaccine under proper conditions as quickly as possible, and 2. Call the Division of Public Health, Immunization Program at (608) 267-5148 to determine whether the potency of the vaccines has been affected.