05-75A50126R00001_RFP Att 4 Agent Request Form.docx

This is an Agent Request Form template used by the BARDA Influenza and Emerging Diseases Division (IEIDD) to track the shipment and receipt of investigational or non-investigational agents, such as vaccines, antigens, and adjuvants related to the influenza vaccine medical countermeasures program.

The form consists of three sections designed to document the complete lifecycle of agent shipments. Section A captures the initial agent request, including the specific agent name, quantity of vials/sprayers/pre-filled syringes or bulk quantities, item lot numbers, concentration levels, and requester authorization with signature and date. Section B documents agent shipment completion, requiring specification of dosage form, volume per unit, lot numbers, and shipment date, along with applicable shipping conditions such as cool packs, dry ice, or temperature monitors, with signature and timestamp verification. Section C provides receipt verification procedures, capturing the quantity received, lot numbers, concentration levels, shipment temperature upon arrival, condition assessment (intact or damaged), and recipient signature with date and time. All received forms must be scanned and submitted to BARDA IEIDD at bai.yeh@hhs.gov to maintain proper documentation and traceability of biological agents and vaccine materials distributed under the pandemic influenza preparedness and response program.