Attachment_3_-_BARDA_Request_for_Shipment.pdf
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- Solicitation number
- 15-100-SOL-00003
About this file
This document contains a federal contract opportunity notice and a related vaccine request form. The federal contract opportunity seeks proposals for the supply of pandemic influenza medical countermeasures including vaccine master seeds, research lots, investigational lots, commercial scale bulk lots, adjuvant bulk lots, formulation and filling services, storage and stability services, shipping, candidate vaccine viruses, potency reagents, analytical testing, non-clinical and clinical studies, disposal services, and additional reporting. Proposals are due February 20th, 2015. The Department of Health and Human Services contemplates single or multiple contract awards to offerors that hold a U.S. influenza vaccine license or have completed Phase 3 clinical trials and have a Biologics License Application in preparation. The base period of performance is three years with two optional one-year extensions. The related vaccine request form provides a template for requesting investigational agents from the contracting office and documenting shipment and receipt.
MCM RFP - Attachment 3 - BARDA Request for Shipment form
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Attachment 3 – 15-100-SOL-00003
BARDA REQUEST FOR SHIPMENT
A. Vaccine Request
Agent Requested: __________________________________________________________
No. of Vials Requested: __________
Requester Signature: _____________________________ Date: _________________
Shipping Address:
B. Investigational Agent Shipment.
Complete the section below send with vaccine to shipping address listed above
Dosage Form: _______________ Volume Per Vial: __________
No. of Vials Shipped: _________ Lot No.: ___________ Shipment Date:_______________
Shipment Conditions (Check all applicable boxes):
Cool Packs Temperature Monitor
Signature Date/Time Shipped
C. Investigational Agent Receipt Verification
Complete the section below upon receipt and scan this form to BARDA ID (Attention: xxx.xxx@hhs.gov)
No. of Vials Received: ____________ Temperature of Shipment Received: ________________
Receipt Condition: Intact Damaged
Signature Date/Time of
Receipt
BARDA Influenza Division Vaccine Request Form
Reason for Shipment: __________________________________________
Shipping Origin Location: _______________________________________ mailto:xxx.xxx@hhs.gov
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