Title Page

  • Site conducted

  • Conducted on

  • Facility and Department

  • Prepared by


  • Have all staff received orientation and/or an annual update on vaccine management?

  • Has the vaccine management policy been reviewed as required and is up to date?

  • Is graph/logbook/chart for temperature recording readily available?

  • Is the temperature of the vaccine refridgerator recorded twice a day when the facility is open?

  • Are the contact numbers to report a cold chain breach easily accessible

  • Were all deviations outside the +2°C to +8°C range reported to pharmacy and IC manager

  • Have the responses to all deviations outside the +2°C to +8°C range been documented and recommended actions taken?


  • Has the refrigerator shown evidence of malfunction (eg poor seals so that the door opens too easily)?

  • Has corrective action been taken?

  • Is there an appropriate gap between the vaccines and the walls of the refrigerator?

  • Can the refrigerator continue to store the required volume of vaccines safely according to these guidelines? (This includes times of increased demand such as the influenza program.)

  • Does the power outlet have a sign ‘Do not turn off or disconnect this refrigerator’?

  • Is the refrigerator plugged into a red OR blue power point?

Monitoring equipment

  • Has the refrigerator been serviced in the past 6 months?

  • Date and results of last Thermometer accuracy check:

Alternative vaccine storage

  • Is there a readily accessible written procedure for what to do during a power failure?

  • Is enough alternative storage (eg cooler, other monitored refrigerator) available for vaccine storage, if necessary (eg vaccine refrigerator breakdown or power failure)?

  • Are ice packs/gel packs at the correct temperature available?

  • Is there one minimum/maximum thermometer for each cooler?

  • Is there enough insulating material for each cooler?

  • Sheet1

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