Vaccine Management Plan

UCSF Medical Center — CDPH VFC compliance program

Thursday, June 4, 2026

VFC Enrollment

Active

Recert in 89d

Staff Training

5/5

Required roles trained

Open Tasks

2

0 overdue · 2 due soon

CAIR2 Sync

6

Doses pending submission

1

Important Contacts

Practice staff and emergency contacts required by the VFC plan

Practice Staff

Provider of Record

Dr. M. Chen

Pediatric Medical Director, MD

(415) 353-4000m.chen@ucsf.edu

Provider of Record Designee

Dr. L. Park

Associate Director, MD

(415) 353-4012l.park@ucsf.edu

Vaccine Coordinator

Aisha Patel

Immunization Program Lead, RN

(415) 353-4118a.patel@ucsf.edu

Backup Vaccine Coordinator

Jordan Kim

Pediatric MA

(415) 353-4119j.kim@ucsf.edu

Emergency Contacts

CDPH Field Representative

Renee Sato

CDPH IZ Branch

(916) 558-1746renee.sato@cdph.ca.gov

VFC Program Representative

VFC Customer Service

MyCAVax Support

(877) 243-8832MyVFCvaccines@cdph.ca.gov

Building Maintenance

UCSF Facilities Dispatch

24/7 line

(415) 476-2021facilities@ucsf.edu

Refrigerator Repair

Follett Service

Authorized vendor

(800) 523-9361service@follettice.com
2

Equipment Documentation

Vaccine storage units, digital data loggers, and calibration timeline

Unit IDTypeLocationDesignationSerialData LoggerProbeAlarms (°F)Calibration Expires
VFC-FR-01
Refrigerator
Benioff-SF · Peds Room AprimaryFF-2C-29021

LogTag UTRIX-16

LT-77104

swappable36462026-09-12

in 101d

PRIV-FR-01
Refrigerator
Benioff-SF · Peds Room AprimaryFF-2C-29022

LogTag UTRIX-16

LT-77105

swappable36462026-09-12

in 101d

VFC-FR-02
Refrigerator
Benioff-Oak · Peds ClinicprimaryFF-2C-30188

LogTag UTRIX-16

LT-77244

swappable36462026-11-04

in 154d

VFC-FZ-01
Freezer
Benioff-SF · PharmacyprimaryFZ-3D-11078

LogTag UTRED30-16

LT-77106

swappable-2252026-08-21

in 79d

VFC-FR-BK
Refrigerator
Parnassus · Peds StoragebackupFF-2C-31501

LogTag UTRIX-16

LT-77351

swappable36462026-07-30

in 57d

Authorized repair: contact Refrigerator Repair in Section 1 emergency contacts.

3

Key Staff Roles & Responsibilities

Designated vaccine management staff and their VFC duties

Provider of Record

Dr. M. Chen, MD

Trained 2026-01-14
  • Sign VFC enrollment annually
  • Final accountability for VFC compliance
  • Approve vaccine orders submitted via MyCAVax

Provider of Record Designee

Dr. L. Park, MD

Trained 2026-01-14
  • Stand in for POR during absences
  • Co-sign storage & handling SOPs

Vaccine Coordinator

Aisha Patel, RN

Trained 2026-01-18
  • Daily temp monitoring (2× per fridge)
  • Monthly physical inventory + form completion
  • Order vaccines through MyCAVax
  • Report SEW events
  • Coordinate CDPH site visits

Backup Vaccine Coordinator

Jordan Kim, MA

Trained 2026-01-22
  • Fill in for Vaccine Coordinator
  • Assist with monthly inventory

Immunizations Lead

Maya Brooks, RN, BSN

Trained 2026-02-03
  • VIS distribution at each visit
  • Eligibility screening
  • Submit dose administration data to CAIR2
4

Initial Equipment Setup Guide

VFC program requirements for storage units and digital data loggers

Storage Unit Requirements

  • • Stand-alone refrigerator and freezer units only — dorm-style and combination units prohibited.
  • • Refrigerated vaccines: 36–46°F (target 40°F). Frozen vaccines: ≤5°F (target 0°F).
  • • VFC and private stock physically separated (Martinez sites use dedicated VFC + private fridges).
  • • Each unit clearly labeled with designation and unit ID matching Section 2 documentation.

Digital Data Logger Requirements

  • • Continuous monitoring with NIST-traceable calibration certificate.
  • • Swappable probe module preferred — allows probe replacement without unit downtime.
  • • Calibration must remain current; recalibrate or replace before listed expiration.
  • • Alarm settings configured for low/high temp; immediate response required on excursion.

Task Schedule

Required cadence per the CDPH vaccine management plan

Daily

Twice-daily temperature monitoring

Record min/max temp per fridge at start and end of clinic day. Document on temperature log.

Last: 2026-06-02 (PM)Next: 2026-06-03 (AM)
On track
Bi-weekly

Supervisor certifies temperature logs

Vaccine Coordinator or POR reviews 2 weeks of twice-daily logs and signs off.

Last: 2026-05-20Next: 2026-06-03
Due soon
Monthly

Physical vaccine inventory + form

Count every dose by lot, verify against MyCAVax records, complete Physical Inventory Form.

Last: 2026-05-15Next: 2026-06-15
On track
Monthly

Expiration check + FIFO rotation

Pull soonest-expiring doses to front; remove expired doses from all units immediately.

Last: 2026-05-15Next: 2026-06-15
On track
Annual

VFC program recertification

POR signs annual provider agreement; coordinators complete refresher training on EZIZ.

Next: 2026-12-01
On track
Annual

Data logger calibration renewal

Replace or recalibrate all data loggers/probes before listed expiration dates.

Next: 2026-07-30
Due soon
As needed

SEW reporting in MyCAVax

Report any Spoiled / Expired / Wasted doses within program timelines; dispose per protocol.

Last: 2026-05-28
Complete

Point-of-Care Scan Inspector

Each scan fans out to 5 systems. Verify the data flow per dose — Apex (Epic) → CAIR2 → inventory → MyCAVax → audit log.

Barcode payload (2D Data Matrix on the vial) carries NDC + lot + expiration + serial — one scan autofills the EHR, decrements the source fridge, sends the HL7 message to CAIR2, and logs to MyCAVax. Scanner blocks administration if NDC doesn't match the order, lot is past expiration, or VFC-eligible patient was matched against private stock.

Spoiled / Expired / Wasted (SEW) Reporting

Reported through MyCAVax, disposed per practice protocol

expired

Tdap (Adacel) · 4 doses

Lot AD-0274-B · Past expiration during low-demand month

2026-05-28

MyCAVaxDisposed
spoiled

MMR (M-M-R II) · 2 doses

Lot MR-1198-A · Brief temp excursion at Parnassus backup fridge

2026-05-12

MyCAVaxDisposed

Report SEW events at mycavax.cdph.ca.gov

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