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Vaccine Supply Chain Logistics Questionnaire

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OPTIMIZE VACCINE SUPPLY CHAIN LOGISTIC COSTING TOOL
FORM IV: HEALTH CENTER QUESTIONNAIRE

Name of interviewee:     Name of health center:

Interviewee title:     District:

Interviewee role:     Region:

Name of interviewer:     Date:

HEALTH FACILITY GENERAL INFORMATION

Cold chain function: Which of the following cold chain functions does the health facility provide? Mark ALL boxes that apply

Mode of routine vaccine supply: How are routine vaccines supplied to this health facility? Mark only ONE box

Health facility energy sources available to power cold chain equipment

Grid electricity: What is the duration of grid electricity access per day for this health facility? Mark only ONE box

Bottled gas: What is the availability of bottled gas for the health facility? Mark only ONE box

Kerosene: What is the availability of kerosene for the health facility? Mark only ONE box

Solar energy: Please indicate the site conditions at the health facility. Mark ALL boxes that apply

POPULATION DATA

2008 2009 2010
Total population
Number of children <12 months of age
Number of pregnant women
Number of women of child-bearing age

DRY GOODS DATA

Wastage rate for syringes: %

Wastage rate for safety boxes: %

VACCINE DATA

Time period for data reported below is: to

Vaccine name:
Annual coverage rate:
Wastage rate:

Month 1 2 3 4 5 6 7 8 9 10 11 12

# of doses in stock

# of doses received

Vaccine name:
Annual coverage rate:
Wastage rate:

Month 1 2 3 4 5 6 7 8 9 10 11 12

# of doses in stock

# of doses received

HUMAN RESOURCES

Complete the following information for each health worker with vaccine or injection supply logistics duties.

Name of health worker:     Job title:     Civil servant grade level:

Responsibilities related to vaccines and dry goods. Check all tasks that apply and fill in the appropriate information for each task.

Task Health worker duties related to vaccines Vaccines Health worker duties related to dry goods Dry goods How often does this activity occur? Average time spent? How often does this activity occur? Average time spent?
ORDERING
Estimating the needs for the health center



COLD CHAIN INVENTORY

Refrigerators/freezers (record data only on those that are currently in working order)

Does this facility have cold chain storage equipment such as refrigerators and freezers?   Fill in a separate line for each refrigerator/freezer found at health facility in the table below.
Proceed to next question on cold boxes and vaccine carriers.

Make Model Year purchased # of units Storage capacity (L) % of capacity used for EPI vaccines

Cold boxes and vaccine carriers

Type Capacity (L) # of units

Ice packs Enter the number of standard ice packs of each size available at the health facility.

0.3 Liter    0.4 Liter    0.6 Liter

TRANSPORTATION

One-way distance (km) between the health center and: District store Regional store National store

Vaccine collection

Collection point for vaccines for this health center:

Number of health workers that travel to collect vaccines:

Number of trips per year to collect vaccines:

Are per diems provided for trips to collect vaccines?

  Amount of per diem per trip:

Dry goods collection

Collection point for dry goods for this health center:

Are dry goods collected on the same trips as vaccines?

Proceed to vaccine transport section.

Number of health workers that travel to collect dry goods:

Number of trips per year to collect dry goods:

Are per diems provided for trips to collect dry goods?

Amount of per diem per trip:

TRANSPORT MODE

Vaccine transport

Is public transport utilized for vaccine transport?

One-way cost per trip:

Number of trips on public transport for vaccine collection in past year:

Is a private vehicle owned by a health care worker utilized for vaccine transport?

Reimbursement per km:

Number of trips in private vehicle for vaccine collection in past year:

Dry goods transport

Is public transport utilized for dry goods transport?

One-way cost per trip:

Number of trips on public transport for dry goods collection in past year:

Is a private vehicle owned by a health care worker utilized for dry goods transport?

Reimbursement per km:

Number of trips in private vehicle for dry goods collection in past year:

Is a health center vehicle owned by the MOH utilized for vaccine and/or dry goods transport?

Fill in the information below in the VEHICLES section for each vehicle.

VEHICLES

Health center vehicle #1

Type:

Make/model:

Year purchased:

Fuel type:

Annual insurance cost:
Annual maintenance cost:
Total km traveled last year:

Health center vehicle #2

Type:

Make/model:

Year purchased:

Fuel type:

Annual insurance cost:
Annual maintenance cost:
Total km traveled last year:

Health center vehicle #3

Type:

Make/model:

Year purchased:

Fuel type:

Annual insurance cost:
Annual maintenance cost:
Total km traveled last year:

Vaccine and dry goods collection trips

Vehicles (please list) # of trips to collect BOTH vaccines and dry goods (A) Total km traveled for collection of BOTH vaccines and dry goods (B) # of trips to collect vaccines ONLY (C) Total km traveled for vaccine collection ONLY (D) # of trips to collect dry goods ONLY (E) Total km traveled for dry goods collection ONLY (F)
Vehicle #1
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What the Vaccine Supply Chain Logistics Questionnaire Is

The Vaccine Supply Chain Logistics Questionnaire is a structured form used to collect standardized operational, storage, transport, and compliance data from suppliers, carriers, healthcare providers, and distribution partners involved in vaccine handling. It verifies cold-chain capacity, temperature monitoring, storage locations, transportation modes, contingency procedures, and responsible contacts. Organizations use the questionnaire to evaluate readiness, document regulatory controls, and support procurement or grant reporting. Responses help risk-assess providers, ensure vaccine integrity during transit and storage, and create a documented basis for contractual and compliance decisions across public and private stakeholders.

Why a Consistent Questionnaire Matters for Vaccine Distribution

A consistent questionnaire standardizes due diligence across suppliers and carriers, reduces ambiguity in cold-chain requirements, and creates an auditable record for regulatory review. Clear, comparable responses lower the chance of storage or transport failures and support faster decision-making.

Why a Consistent Questionnaire Matters for Vaccine Distribution

Who Typically Completes and Reviews This Questionnaire

The questionnaire is completed by operational staff at vendors, logistics providers, healthcare facilities, and public health agencies to capture technical and compliance information before awarding contracts or approving shipments.

  • Logistics Providers: Warehouse and carrier operations teams complete technical fields about cold storage, transport vehicles, and temperature control procedures.
  • Healthcare Facilities: Pharmacy and immunization clinic staff report on in-house storage capacity, inventory controls, and local contingency plans.
  • Government Agencies: Public health procurement and program managers review submissions to ensure regulatory alignment and supply-chain resilience.

Reviewers include procurement teams, quality assurance, compliance officers, and immunization program managers who rely on this data to approve partners and document capabilities.

Essential Sections to Include in a Professional Questionnaire

A professional Vaccine Supply Chain Logistics Questionnaire collects contact details, cold-chain equipment specifications, transport modes, monitoring and alarm procedures, personnel training, and contingency plans so responses can be compared and validated across bidders.

Contact Details

Provide legal entity name, primary contact, role, phone, and email. Accurate contacts speed issue resolution and form the basis for contractual notices.

Storage Capacity

List storage locations, capacity by temperature range (ultra-cold, frozen, refrigerated), and backup power sources. This data verifies the ability to hold vaccine volumes safely.

Transport Details

Describe vehicle types, active or passive refrigeration, route plans, and estimated transit times. Include any temperature validation or qualification reports.

Monitoring & Alerts

Specify continuous temperature monitoring technology, alarm thresholds, alert recipients, and data retention policy for monitoring logs and audit trails.

Personnel & Training

List staff roles with cold-chain training certifications, frequency of retraining, and responsible supervisors to ensure proper handling and response to excursions.

Contingency Plans

Detail emergency transfer procedures, alternate storage partners, insurance coverage, and communication protocols for temperature excursions or delays.

Core Data Fields Required

Legal Entity: Full registered name
Primary Contact: Name and title
Facility Address: Street, city, state, ZIP
Storage Types: Ultra-cold/frozen/refrigerated
Monitoring Method: Continuous or manual
Data Retention: Retention period

Step-by-Step: Completing and Submitting the Questionnaire

Follow these steps to complete the questionnaire in order and ensure timely review and acceptance by procurement and compliance teams.

  • 01
    Gather Documents: Collect SOPs, monitoring logs, and equipment spec sheets.
  • 02
    Complete Fields: Fill every required box using prescribed formats.
  • 03
    Attach Evidence: Upload calibration certificates and monitoring export files.
  • 04
    Submit and Certify: Sign, date, and send to the designated reviewer.

Recommended Digital Workflow Configuration

Configure an electronic workflow that maps each questionnaire field to validation rules, required attachments, and approvers to reduce manual checks.

Field Configuration
Contact Verification Require email validation and phone entry
Temperature Fields Numeric-only; units required
Attachments Make calibration certificate mandatory
Approvals Route to QA and procurement sequentially

Digital Platform Essentials for eSubmission

Platforms that integrate with enterprise systems (CRM, document storage) and offer encryption at rest and in transit reduce friction and support audits.

  • File Formats: Accept PDF, DOCX, XLSX
  • Authentication: Email or SMS code options
  • Audit Trail: Store IP, timestamp, and actions

Typical eSubmission and Approval Flow

A straightforward electronic flow reduces processing time and creates a reproducible record for audits and contract files.

  • Upload: Sender uploads questionnaire and attachments
  • Validate: Platform checks required fields and formats
  • Sign: Authorized representative signs electronically
  • Archive: Signed copy and audit trail stored securely

Typical Timelines and Processing Expectations

Establish and communicate timelines for completion, review, and approval to align supply planning and shipment windows.

Response Window:

7–14 days to return completed questionnaire

Initial Review:

3–5 business days for procurement screening

Technical Review:

5–10 business days for QA and cold-chain validation

Contract Approval:

Variable; typically 7–21 days depending on complexity

Re-validation:

Annual or when major process changes occur

Common Mistakes to Avoid When Preparing Responses

  • Incomplete temperature data or missing units (°C vs °F) leads to costly follow-up and may disqualify a vendor from consideration.
  • Uploading unreadable attachments or expired calibration certificates undermines the credibility of monitoring claims and delays approvals.
  • Providing generic contingency language instead of specific alternate storage partners and contact details increases procurement risk and may trigger additional requirements.
  • Mismatched legal entity names or missing signatory authority can invalidate submissions and prevent contract execution.

Penalties and Compliance Risks for Inaccurate or Missing Information

Regulatory Audit: Findings may trigger corrective actions
Contractive Liability: Breach claims and indemnity exposure
Product Loss: Financial loss from spoiled vaccine
Data Retention Breach: HIPAA exposures if PHI mishandled
Federal Reporting: Grant or procurement noncompliance
Criminal Risk: Intentional falsification may carry penalties

eSignature Vendor Pricing Snapshot for Questionnaire Workflows

Compare baseline pricing and common features for eSignature providers used to collect and certify questionnaire responses. signNow appears first per comparative format.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently Asked Questions About the Questionnaire

Answers to common questions about legality, eSigning, notarization, evidence, and recordkeeping when using the Vaccine Supply Chain Logistics Questionnaire.


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