VFC Transition
Fridge/Freezer Survey	

Dear Immunization Provider,

As part of our ongoing efforts to ease the transition of offices to VFC Only vaccine supplied by the State of Maine Immunization Program, we are offering complementary fridge and freezer units for your use in separating and managing State Supplied vaccine.

Completion of this survey does not guarantee delivery of the indicated product(s).
We will be reviewing your responses and may contact you for further information.  
In order to gauge the need within the provider offices, 

Please complete a new sheet for each physical location you manage.

Please return this survey by Friday, December 5th, 2008.

If you have received this survey by Fax, please complete the survey and fax it back:
ATTN Terri Nickerson @ 1-207-287-8127

If you have received this survey by ListServ/E-Mail, you may;

please complete the document and e-mail it to
Terri Nickerson at Terri.Nickerson@maine.gov
Please use the subject line: 2008 Fridge/Freezer Survey

Or complete the survey and fax it back:
ATTN Terri Nickerson @ 1-207-287-8127

 We apologize for having to request an expedited response.

	VFC Transition
Fridge/Freezer Survey	
Introduction – VFC Transition: Securing and Managing State Supplied Vaccine	

Completion of this survey does not guarantee delivery of the indicated product(s).
We will be reviewing your responses and may contact you for further information.  
Please complete a new sheet for each physical location you manage.
	
SECTION 1 - GENERAL INFORMATION	

1.1  CONTACT NAME - LAST, FIRST, MIDDLE

1.2  FACILITY PIN

1.3  FACILITY NAME

1.4  PHYSICAL ADDRESS

1.5  CONTACT PHONE

(207)  	
1.6  CONTACT FAX

(207) 	

1.7  # of LOCATIONS (including this one)

	 	
1.8 OTHER COMMENTS:	
SECTION 2 – ASSESSMENT OF NEED	
Please provide an answer to all questions.	

2.1 FRIDGE REQUIREMENTS:  

2.1.1 Do you need 1 or more Fridge Units?
	
 Yes	Exceeded	
 No	

2.1.2 How many fridge units do you need for this site?
	
 One	Exceeded	
 Two	
 Three	Exceeded	
 Four	

2.2 FREEZER REQUIREMENTS:  

2.2.1 Do you need 1 or more Freezer Units?
	
 Yes	Exceeded	
 No	

2.2.2 How many freezer units do you need for this site?
	
 One	Exceeded	
 Two	
 Three	Exceeded	
 Four	

REFRIDGERATOR	FREEZER	
•	Manual defrost
•	R-134a CFC-free refrigerant
•	240w compressor
•	Key-locked door with flat door liner, open from left
Specifications & Ordering Information: 
Interior dimensions: 13D x 19W x 271/2 in.H (33 x 48 x 70cm).
Exterior: 241/2L x 231/2W x 33 in.H (62 x 60 x 84cm)
Net weight, 90 lb. (40.8kg). 
120V 60Hz, 2A; 15A breaker.	•	Capacity: 5.6 cu. ft. (159L)
•	R-134a CFC-free refrigerant
•	Base-mounted 360w compressor
•	Solid door is mounted to open from left
Specifications & Ordering Information: 
Interior dimensions: 15D x 18W x 271/2 in.H (38 x 46 x 70cm). Exterior: 251/4L x 211/4W x 331/2 in.H (64 x 54 x 85cm)
Net weight: 90 lb. (40.8kg); 
120V 60Hz, 3/15 amps/breaker.