**2008 VFC Provider Site Visit Questionnaire**

**All Grantees (includes all vaccine purchase policies)**

***(This form is to be completed by the public health official who is
conducting the site visit review. Section I of this questionnaire is
considered the CDC minimum standard for conducting routine VFC provider
site visits. Immunization Projects should incorporate these standard
questions into their existing VFC site visit protocols and VFC provider
on-site questionnaires. Section II is based on the Standards of
Pediatric Care. Completion of Section II is optional.)***

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Reviewer's Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider Site Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provider address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact person: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Telephone & FAX Numbers:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
VFC Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

County: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Region: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Note: ! An incorrect or inappropriate response to any question marked
with this icon automatically requires that a corrective action be
recommended.**

Type of Practice:

Public hospital based clinic Private Practice Public Health Dept Clinic
Military Health Care Facility Private hospital based clinic FQHC/RHC
Private Preschool/daycare/etc Public Preschool/daycare/etc

Substance abuse WIC Indian Health Center Corrections Facility

HIV/STD Clinic

How many physicians are practicing at this site? \_\_\_\_\_\_\_

The following question should be answered prior to the site visit, so
the findings can be discussed during the site visit.

**!**Are vaccine orders consistent with most current provider profile?
\_\_\_\_\_ If no, follow up actions must be documented in 32b.

**[SECTION I. VFC COMPLIANCE]{.underline}**

**Questions 1-7 should be answered by the provider.**

1.  **!** What is the vaccine administration fee charged to non-Medicaid
    VFC eligible patients (uninsured, American Indian/Alaska Native,
    under-insured if vaccinated at FQHC/RHC)? \_\_\_\_\_\_\_\_\_

2.   Under what circumstances is a child referred to another facility
for immunization services?

>   Not applicable children are never referred

              Child is underinsured
                                         Vaccine is
unavailable          

              Parent is unable to pay administration fee         
Parent is unable to pay office visit fee

              Other
(specify)                                                                                                                

3.  Which of the following vaccines are **NOT** routinely administered
    in this clinic/practice?

DTaP Influenza Pneumococcal Polysaccharide**\***

Hepatitis A Meningococcal Conjugate Polio

Hepatitis B MMR Rotavirus

HIB MMR-V Td

Human Papillomavirus Pneumococcal Conjugate Tdap

Varicella

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**\*** *to high-risk patients*

4.  **!** When does this clinic/practice provide patients with copies of
    the Vaccine Information Statements (VIS) to keep?

> Every time the patient receives a vaccination

When the child receives the first dose of vaccine within a particular
series (e.g. 1^st^ dose of DTaP)

Do not provide

Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

5.  In order to complete the annual provider profile, how does this
    clinic/practice determine the number of VFC-eligible patients in
    this clinic/practice?

> Use doses administered data
>
> Use benchmarking data
>
> Use Medicaid & billing data
>
> Immunization Information System (Registry)
>
> Other (please describe):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  **!** When does the clinic/practice screen patients for VFC
    eligibility?

> First immunization visit to the office
>
> Every immunization visit
>
> Do not screen for VFC eligibility

Not applicable, clinic/practice serves 100% VFC eligible children and
has appropriate Comprehensive Certification form with up to date
signature on file

> Other (specify)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7.  ! Does this clinic/practice always notify the Immunization Program
    when publicly purchased vaccine has been involved in a cold chain
    failure, has expired or been wasted?

Yes No

8.  ! When does this clinic/practice prepare vaccine for administration
    to patient?

Immediately before administration Other: specify
process:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Questions (9-28) should be answered based on a physical review of
provider's written plan, VISs, refrigerator(s) and freezer(s).**

9.  **!** Does the clinic/practice have a **written plan** for vaccine
    management including the following ( review for accurate content):

  ------------------------------------------------- ---------- ----------
                                                    **Yes**    **No**

  Designation of primary vaccine coordinator and at            
  least one back-up staff                                      

  Proper vaccine storage and handling                          

  Vaccine shipping (includes receiving, &                      
  transport)                                                   

  Procedures for vaccine relocation in the event of            
  a power failure, mechanical difficulty or                    
  emergency situation (emergency plan)                         

  Has the emergency plan been reviewed or updated              
  annually or since change in responsible staff?               

  Vaccine ordering                                             

  Inventory control (e.g. stock rotation)                      

  Vaccine wastage                                              
  ------------------------------------------------- ---------- ----------

10. ! Please identify the publication date for each of the VIS currently
    being used in this clinic/practice and then check the appropriate
    status for each VIS.

  ---------------------------------------------- ------------------- -------------- ------------ --------------
  **VACCINE^\*^**                                **VIS VERSION BEING                             
                                                 USED IN THIS                                    
                                                 CLINIC/PRACTICE**                               

                                                 **Current**         **Outdated**   **None       **Does Not
                                                                                    Used**       Administer**

  DTaP (5/17/07)                                                                                 

  Polio (1/1/00)                                                                                 

  MMR (1/15/03)                                                                                  

  Hepatitis B (7/18/07)                                                                          

  Varicella (01/10/07)                                                                           

  Hepatitis A (3/21/06)                                                                          

  Hib (12/16/98)                                                                                 

  Pneumococcal Conjugate (9/30/02)                                                               

  Inactivated Influenza (07/16/07)                                                               

  Live Intranasal Influenza (07/16/07)                                                           

  Td (6/10/94)                                                                                   

  Adult Pneumococcal Polysaccharide (PPV23)                                                      
  (7/29/97)                                                                                      

  Meningococcal (08/16/07)                                                                       

  Tdap (07/12/06)                                                                                

  Rotavirus (4/12/06)                                                                            

  Human Papillomavirus (2/02/07)                                                                 

  Other                                                                                          
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                   
  ---------------------------------------------- ------------------- -------------- ------------ --------------

> *VIS Website: <http://www.cdc.gov/vaccines/pubs/vis/default.htm>
> Current VIS publication dates as of 09/26/2007*

11. **!** What type of storage units does this clinic/practice use to
    store varicella-containing vaccines and all other vaccines? (check
    all that apply)

  -----------------------------------------------------------------------
  **Varicella Containing Vaccines**  **All Other Vaccines**
  ---------------------------------- ------------------------------------
  Stand alone freezer                Stand alone freezer

  Stand alone refrigerator           Stand alone refrigerator

  Dormitory style                    Dormitory style refrigerator/freezer
  refrigerator/freezer               

  Combined refrigerator/freezer with Combined refrigerator/freezer with
  separate external refrigerator and separate external refrigerator and
  freezer doors (e.g. household      freezer doors (e.g. household style
  style appliance).                  appliance).

  Combined refrigerator/freezer with Combined refrigerator/freezer with
  single door                        single door

  Does not administer vaccines       
  requiring freezer storage          
  -----------------------------------------------------------------------

12. **!** Are working thermometers placed in a central area of each
    refrigerator and freezer?

  --------------------- ------------------ ----- ----- ----- ----- ------------- ----- ----- ----- -----
                        **Refrigerator**                           **Freezer**                     

                        #1.                #2.   #3.   #4.   #5.   #1.           #2.   #3.   #4.   #5.

  **Yes**                                                                                          

  **Have thermometer                                                                               
  but not placed                                                                                   
  properly**                                                                                       

  **No thermometer**                                                                               
  --------------------- ------------------ ----- ----- ----- ----- ------------- ----- ----- ----- -----

13. \(A\) What type of thermometer is used by the clinic/practice (check
    all that apply)?

  -------------- ------------------ ----- ----- ----- ----- ------------- ----- ----- ----- -----
                 **Refrigerator**                           **Freezer**                     

                 #1.                #2.   #3.   #4.   #5.   #1.           #2.   #3.   #4.   #5.

  **Standard                                                                                
  Fluid Filled**                                                                            

  **Continuous                                                                              
  Recording**                                                                               

  **Min-Max**                                                                               

  **Dial**                                                                                  

  **Digital**                                                                               

  **Other                                                                                   
  (specify)**                                                                               
  -------------- ------------------ ----- ----- ----- ----- ------------- ----- ----- ----- -----

13\. (B) **!** For each type of thermometer used by the clinic/practice,
indicate if the thermometer is certified (check all that apply).

<table style="width:100%;">
<colgroup>
<col style="width: 13%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td></td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><strong>Standard Fluid Filled</strong></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
</tr>
<tr class="even">
<td><strong>Continuous Recording</strong></td>
<td><p><strong>YES__</strong></p>
<p><strong>No ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
</tr>
<tr class="odd">
<td><strong>Min-Max</strong></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
</tr>
<tr class="even">
<td><strong>Dial</strong></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
</tr>
<tr class="odd">
<td><strong>Digital</strong></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
</tr>
<tr class="even">
<td><strong>Other (specify)</strong></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES___</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
<td><p><strong>YES__</strong></p>
<p><strong>NO ___</strong></p></td>
</tr>
</tbody>
</table>

14. ! For each refrigerator and freezer indicate how often temperatures
    are recorded (check all that apply).

  ------------------------- ------------------ ----- ----- ----- ----- ------------- ----- ----- ----- -----
                            **Refrigerator**                           **Freezer**                     

                            #1.                #2.   #3.   #4.   #5.   #1.           #2.   #3.   #4.   #5.

  **Once a day**                                                                                       

  **Less than once a day**                                                                             

  **Twice a day**                                                                                      

  **More than twice a day**                                                                            
  ------------------------- ------------------ ----- ----- ----- ----- ------------- ----- ----- ----- -----

15. Record the highest and lowest temperatures logged in the last 3
    months. If no log is available for the past three months, record the
    highest and lowest temperatures from available logs.

> Please indicate if recordings are Celsius (^o^C) or Fahrenheit
> (^o^F*).*
>
> ***Recommended temperature ranges: Refrigerator: (2-8°C / 35-46°F)
> Freezer :(-15°C / 5°F or lower)***

<table>
<colgroup>
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Refrigerator</strong> (2-8°C / 35-46°F)</td>
<td colspan="5"><strong>Freezer</strong>(-15°C / 5°F or lower)</td>
</tr>
<tr class="even">
<td></td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><strong>Lowest</strong></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____′F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
</tr>
<tr class="even">
<td><strong>Highest</strong></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
</tr>
<tr class="odd">
<td><strong>Log available for last 3 months?</strong></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

If any of the lowest and/or highest temperatures are out of the
recommended range then **GO TO** question 16. If the temperatures are
within the recommended guidelines, **SKIP** to question 19.

16. **!** During past 3 months, how many times were the temperatures
    outside the recommended range?

<table>
<colgroup>
<col style="width: 28%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><p><strong>Refrigerator</strong></p>
<p>(2-8°C / 35-46°F)</p></td>
<td colspan="5"><p><strong>Freezer</strong></p>
<p>(-15°C / 5°F or lower)</p></td>
</tr>
<tr class="even">
<td></td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><strong>Below Guidelines</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><strong>Above Guidelines</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

17. **!** When the temperatures were outside the recommended range, what
    action did the clinic/practice take?

> *( all that apply)*

Adjusted thermostat in refrigerator/freezer

Measured temperature with different thermometer to check accuracy of
original reading

Moved vaccine to a different refrigerator/freezer maintained at proper
temperature

Called the vaccine manufacturer to determine the potency of the vaccine

Called the local/state immunization program for assistance

Did not do anything

18. ! Does the clinic/practice have written documentation of the action
    taken when the temperatures were outside the recommended range?

> Yes No

19. Record the current temperatures

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="5"><p><strong>Refrigerator</strong></p>
<p>(2-8°C / 35-46°F)</p></td>
<td colspan="5"><p><strong>Freezer</strong></p>
<p>(-15°C / 5°F or lower)</p></td>
</tr>
<tr class="even">
<td></td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><strong>Practice Thermometer</strong></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
</tr>
<tr class="even">
<td><strong>Reviewer’s Thermometer</strong></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
<td><p><strong>____°C</strong></p>
<p><strong>____°F</strong></p></td>
</tr>
</tbody>
</table>

20. **!** Are current temperatures within the guidelines according to
    the reviewer's thermometer?

(Refrigerator: 2-8°C / 35-46°F, Freezer: -15°C / 5°F or lower)

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

21. **!** Is food stored with vaccines in the refrigerator or freezer?

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

22. **!** Are vaccines stored in the doors of the refrigerator or
    freezer?

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

23. ! Is vaccine stored in the middle of the storage unit and stacked
    with air space between the stacks and side/back of the unit to allow
    cold air to circulate around the vaccine?

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

24. **!** Is there a "DO NOT DISCONNECT" sign on the
    refrigerator/freezer electrical outlet?

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

25. **!** Is there a "DO NOT DISCONNECT" sign on the circuit breaker?

> Yes No Don't Know

26. **!** Are short-dated vaccines stored in front and used first,
    rotating stock effectively?

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Refrigerator</strong></td>
<td colspan="5"><strong>Freezer</strong></td>
</tr>
<tr class="even">
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
<td>#1.</td>
<td>#2.</td>
<td>#3.</td>
<td>#4.</td>
<td>#5.</td>
</tr>
<tr class="odd">
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
<td><p><strong>YES</strong></p>
<p><strong>NO</strong></p></td>
</tr>
</tbody>
</table>

27. **!** Can the clinic/practice physically differentiate privately
    purchased vaccine from publicly purchased vaccine? To answer yes,
    clinic/practice must be able to demonstrate how this is done.

Yes, clinic/practice can physically differentiate public vaccine from
private vaccine

No, clinic/practice cannot physically differentiate public vaccine from
private vaccine

Not applicable, clinic/practice is located in a universal state, has no
private stock

Not applicable, clinic/practice serves 100% VFC eligible children, has
no private stock

Other

28. ! Upon checking the clinic/ practice's vaccine supply, did the
    reviewer find any unreported wasted or expired vaccine?

Yes No

**Questions 29 - 31 should be answered based on a review of patient
charts, electronic medical records, or patient log (electronic or
manual) or registry which records VFC eligibility status.**

29. What is the VFC eligibility screening coverage in this
    clinic/practice?

VFC screening coverage of 100%

VFC screening coverage of at least 95%

VFC screening coverage of at least 90%

VFC screening coverage below 90%

30. What methodology was used to determine VFC eligibility screening
    coverage during this site visit?

CDC-supplied Lot Quality Assurance (LQA) protocol

CoCASA

Grantee-developed methodology

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

31. Do all immunization records contain the following documentation
    required by statute 42 US Code 300aa-25? *( one box per item)*

  --------------------------------------------------- --------- ---------
  **Required Documentation**                          **Yes**   **No**

  Name of vaccine given                                         

  Date vaccine was given                                        

  Date VIS was given                                            

  Name of vaccine manufacturer                                  

  Lot number                                                    

  Name and title of person who gave the vaccine                 

  Address of clinic where vaccine was given                     

  Publication date of VIS                                       
  --------------------------------------------------- --------- ---------

**Questions 32-33 should be answered based on results of the VFC site
visit.**

32a. Are corrective actions recommended for this VFC enrolled site?

Yes No *(STOP here*)

32b. Please indicate which corrective actions regarding vaccine
practices were recommended for this VFC-enrolled site. Please refer to
high-risk question (**! )** key to determine what questions were
answered inappropriately. All questions answered with inappropriate
responses require corrective actions. The reviewer may also enter
corrective actions for non high-risk questions. Enter all recommended
corrective actions in the appropriate space provided below. *( all that
apply and specify problem)*

Administrative practices
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Vaccine storage and handling
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

33\. Please indicate your plan for following-up with the site to ensure
recommendations were implemented.

Provided technical assistance at time of site visit, no further
follow-up is needed

Telephone call

Site visit

F/U letter

Suspended delivery of VFC vaccine until storage/handling problems
resolved

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[SECTION II. Standards for Pediatric & Adolescent Immunization
Practices (Optional)]{.underline}**

[Vaccine Administrative Policy]{.underline}

1.  How does the clinic/practice offer immunization services to
    patients? (Check all that apply)

 During well-child visits  Immunization-only appointments 

 Walk-in immunizations  Dedicated days/times for immunizations

 Off-site immunizations  Other (specify)

2.  Is an office visit fee charged in addition to any vaccine
    administration fees?

 Yes  No

If yes, what is the amount of the office visit fee?

3.  Is a physical exam required before immunizations are given?

 Yes  No

[Assessment of Vaccination Delivery]{.underline}

4\. Does the clinic/practice routinely immunize when the child has:

  -------------------------------------- --------- -------- -----------------
                                         **Yes**   **No**   **Situational**

  A cold                                                  

  Low grade fever (e.g. 100.4°F \[38°C\]                  
  or lower)                                                 

  Recently been exposed to infectious                     
  illness                                                   

  Mild diarrhea                                           

  Convalescing from an acute illness                      
  -------------------------------------- --------- -------- -----------------

[Effective Communication about Vaccine Benefits and Risks]{.underline}

5.  Does the clinic/practice staff know how to obtain foreign-language
    Vaccine Information Statements (VIS) for patients/families whose
    first language is not English?

 Yes  No

[Proper Storage and Administration of Vaccines and Documentation of
Vaccinations]{.underline}

6.  Does the clinic/practice have a current copy of the following
    documents?

  ------------------------------------------------------------- --------- --------
                                                                **Yes**   **No**

  *Recommended Childhood Immunization Schedule*                          

  *Revised Standards for Child and Adolescent Immunization               
  Practices*                                                              

  *Contraindications for Childhood Immunization*                         

  *Vaccine Management: Recommendations for Handling & Storage            
  of Selected Biologicals*                                                
  ------------------------------------------------------------- --------- --------

7.  Are up-to-date, written vaccination protocols accessible at all
    locations where vaccines are administered? (If Yes, ask to see a
    copy)

 Yes  No

8.  Who gives immunization injections? (Check all that apply)

 MD  NP  PA  RN  LVN  LPN  MA

9.  How do persons who administer vaccines and staff who manage or
    support vaccine administration receive ongoing education regarding
    immunization? (Check all that apply.)

>  No ongoing training  In-house training by health dept./professional
> organization at least once a year

 In-house training by staff at least once a year  Off-site conferences
or workshops at least once a

year

>  Distribution of written materials  Web-based training

 Other (specify)

10. Does the practice document ongoing education regarding immunization
    for persons who administer vaccines and staff who manage or support
    vaccine administration?

 Yes  No

11. Does the clinic/practice simultaneously administer all vaccines for
    which the child is eligible?

 Yes  No

12. What size needles are generally used for intramuscular injections?

 5/8 " (inch)  1 " (inch)  7/8" (inch)

 Depends on age  Other (Specify):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

13. Does the clinic/practice pre-fill syringes?

 Yes  No

14. Does the clinic/practice have VAERS forms and know how to report to
    VAERS?

 Yes  No

15. Does the clinic/practice require staff who have contact with
    patients to be immunized or show proof of immunity against the
    following vaccine-preventable diseases? (Check all that apply)

 None required  Measles/Mumps/Rubella  Hepatitis B

 Hepatitis A  Varicella  Influenza

 Td  Other (specify)

[Implementation of Strategies to Improve Vaccination
Coverage]{.underline}

16. How does the clinic/practice remind patients of their next
    appointment? (Check all that apply)

 Mail  Written appointment slip given at last visit

 Telephone  Does not remind patients of next appointment

 Verbally at last visit  Other (specify)

17. How does the clinic/practice contact patients who miss their
    appointments? (Check all that apply)

 Mail  Telephone

 Does not contact patients who miss their appointments

 Other (specify)

18. How does the clinic/practice identify patients if no appointment is
    made and immunizations are due/overdue? (Check all that apply)

 Cannot identify patients due/overdue for immunizations  Immunization
registry

 Computer (office-based, not connected to a registry)  Paper-based
"tickler" system

 Other (specify)

> 19\. How frequently does the clinic/practice generate reminder/recall
> notices (or phone calls) to patients who are due/overdue for a
> vaccination? (Check all that apply)

 Quarterly  Monthly  No regular schedule

 Weekly  Clinic/practice does not distribute recall notices to
patients

20. Is an office- or clinic-based patient record review and vaccination
    coverage assessment performed at least once a year (check all that
    apply)?

>  No  Yes  Yes, by practice staff

 Yes, by immunization/VFC program  Yes, by other external reviewer

> When was the most recent office- or clinic-based patient record review
> and vaccination coverage assessment?

Date:

21. Does the practice/clinic participate in an immunization registry?

 Yes  No

22. What community-based approaches does the clinic/practice use to
    increase immunization coverage? (Check all that apply)

>  No community-based approaches used  Participates in health fairs
>
>  Provides off-site immunization services  Conducts community-based
> outreach/education
>
>  Partners schools/school nurses  Other (specify)
>
> <http://www.cdc.gov/vaccines/programs/vfc/downloads/2008-vfc-site-visit-questionnaire.doc>