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Forms & Templates

On this page, you will find various forms that Military Health System uses to support its programs. Please scroll down the page or use the search box to find specific forms and templates.

Please note that files more than two years old may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.

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Potentially Compromised Temperature Sensitive Medical Products (PC TSMP) Worksheet

Form/Template
8/21/2019

This worksheet is used when vaccines have been potentially compromised and a disposition is required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

CIS Essentris PIA

Form/Template
8/19/2019

This Privacy Impact Assessment (PIA) documents compliances for CIS-Essentris

PC TSMP Worksheet (Continuation Sheet)

Form/Template
8/13/2019

This is a continuation sheet for the PC TSMP worksheet when additional worksheets are required.

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Fahrenheit

Form/Template
8/12/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/12/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Offsite Clinic FROZEN Vaccine Inventory Issue Return Receipt and Temp Log Celsius

Form/Template
8/12/2019

When transporting vaccine off-site, you must log their storage temperature every hour to ensure they are kept at the required temperature range for the duration of the event.

Recommended Content:

Vaccine Storage and Handling

Steps to take for Potentially Compromised Vaccine Event

Form/Template
8/12/2019

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Storage Unit Sticker Template

Form/Template
8/12/2019

Some resources you can use to protect your vaccine storage unit and warn staff to not turn off power to the unit.

Recommended Content:

Vaccine Storage and Handling

Emergency Vaccine Retrieval and Storage Plan Worksheet

Form/Template
8/12/2019

Recommended Content:

Vaccine Storage and Handling | Potential Vaccine Compromise Reporting

Freezer Temperature Log - Fahrenheit

Form/Template
8/12/2019

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Freezer Temperature Log - Celsius

Form/Template
8/12/2019

Temperature log for freezers storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Fahrenheit

Form/Template
8/12/2019

Monitoring the temperature of your vaccine storage unit is required at least twice a day, and should be logged using this form.

Recommended Content:

Vaccine Storage and Handling

Refrigerator Temperature Log - Celsius

Form/Template
8/12/2019

Temperature log for refrigerators storing vaccines.

Recommended Content:

Vaccine Storage and Handling

Theater Medical Information Program-Joint Composite Health Care System Caché (TC2).

Form/Template
8/5/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Theater Medical Information Program-Joint Composite Health Care System Caché (TC2).

Defense Occupational and Environmental Health Readiness System - Industrial Hygiene (DOEHRS-IH)

Form/Template
7/22/2019

This Military Health System (MHS) Privacy Impact Assessment (PIA) summarizes the Defense Occupational and Environmental Health Readiness System - Industrial Hygiene (DOEHRS-IH) system.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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