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<br />" <br /> <br />REPORTING REQUIREMENTS <br /> <br />PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunization Division, <br />by January 31st of each year, a report detailing storage measures and methods used to control <br />vaccine loss including methods to monitor and record daily vaccine storage temperatures. The <br />report will be submitted in a fonnat provided each year by RECEMNG AGENCY, Immunization <br />Division. <br /> <br />PERFORMING AGENCY agrees to provide RECEIVING AGENCY, Immunization Division, <br />monthly reports of vaccine utilization/loss, within ten days after the end of each month, on forms <br />provided by RECEMNG AGENCY (Fonns C5, C33, C33A). Computer generated fonns in the <br />same fonnat and containing the required infonnation are acceptable. PERFORMING AGENCY <br />further agrees to provide copies of each Biological Fonn (C-68) used to transfer vaccines to <br />another agency or private provider. Vaccine lot numbers must be included on all Biological <br />Forms used to transfer vaccines. Status reports of program activities must be submitted to the <br />RECEMNG AGENCY quarterly, using the most current "Immunization Program Performance <br />Indicators Report" fonnat. PERFORMING AGENCY will be evaluated on: the number of doses <br />administered, the number of DTP 4 administered to children who are two years old and younger <br />and immunization levels of two year old children. <br /> <br />PERFORMING AGENCY agrees to provide to RECEMNG AGENCY, Immunization Division, <br />weekly reports of all immunizations given, detailed by client demographic and dose infonnation. <br />The report will be submitted in a fonnat provided by RECEMNG AGENCY, Immunization <br />Division. <br /> <br />Status reports of program activities must be submitted to the RECEMNG AGENCY using the <br />most current "Immunization Program Perfonnance Indicators Report". Immunization data (doses <br />administered by age, schedule, and patient demographics) must be provided in a fonnat that may <br />be loaded directly into the electronic Immunization Tracking System (ImmTrac). Report fonnats <br />have been supplied to PERFORMING AGENCY. PERFORMING AGENCY will be evaluated <br />on both the number of doses administered and the number of DTP 4 administered to children who <br />are two years old or younger. <br /> <br />PERFORMING AGENCY agrees to comply with the following: Texas Immunization Laws, <br />Rules, and Regulations: 942.043 Texas Human Resources Code; 9938.001-38.002 Texas <br />Education Code; 9981.023, 161.001-161.006 Texas Health and Safety Code; 25 T.A.C. 9997.61- <br />97.77,97.101-97.102, and 42 U.S.C. 9247b as amended. <br /> <br />ATTACHMENT - Page 4 <br />