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: __________________
Reviewers 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
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_____
Hepatitis A______
Hepatitis B______
HIB__________
Human Papillomavirus________
Influenza______
Meningococcal Conjugate_________
MMR________
MMR-V__________
Pneumococcal Conjugate__________
Pneumococcal Polysaccharide*________
Polio___________
Rotavirus_____________
Td__________
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. 1st 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 providers 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):
Designation of primary vaccine coordinator and at least one back-up staff?
Yes____
or
No_____
Proper vaccine storage and handling?
Yes____
or
No_____
Vaccine shipping (includes receiving, & transport)?
Yes____
or
No_____
Procedures for vaccine relocation in the event of a power failure,  mechanical difficulty or emergency situation (emergency plan)?
Yes____
or
No_____
Has the emergency plan been reviewed or updated annually or  since change in responsible staff?
Yes____
or
No_____
Vaccine ordering?
Yes____
or
No_____
Inventory control (e.g. stock rotation)?
Yes____
or
No_____
Vaccine wastage?
Yes____
or
No_____
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, Used, Does Not Administer)
DTaP (5/17/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Polio (1/1/00)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
MMR (1/15/03)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Hepatitis B (7/18/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Varicella (01/10/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Hepatitis A (3/21/06)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Hib (12/16/98)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Pneumococcal Conjugate (9/30/02)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Inactivated Influenza (07/16/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Live Intranasal Influenza (07/16/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Td (6/10/94)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Adult Pneumococcal Polysaccharide (PPV23) (7/29/97)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Meningococcal  (08/16/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Tdap (07/12/06)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Rotavirus (4/12/06)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Human Papillomavirus (2/02/07)
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
Other ______________________
Current_________
Outdated________
None_______
Used________
Does Not Administer_______
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:
Stand alone freezer____
Stand alone refrigerator____
Dormitory style refrigerator/freezer____
Combined refrigerator/freezer with separate external refrigerator and freezer doors (e.g. household style appliance). ___________
Combined refrigerator/freezer with single door_________
Does not administer vaccines requiring freezer storage______
All Other Vaccines:
Stand alone freezer____
Stand alone refrigerator____
Dormitory style refrigerator/freezer____
Combined refrigerator/freezer with separate external refrigerator and freezer doors (e.g. household style appliance). ___________
Combined refrigerator/freezer with single door_________
12. !Are working thermometers placed in a central area of each refrigerator and freezer?
Refrigerator:
1.
Yes______
Have the thermometer but not placed properly_______
No thermometer_________
2.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
3.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
4.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
5.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
Freezer:
1.
Yes______
Have the thermometer but not placed properly_______
No thermometer_________
2.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
3.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
4.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
5.Yes______
Have the thermometer but not placed properly_______
No thermometer_________
13. (A) What type of thermometer is used by the clinic/practice (check all that apply)?
Refrigerator:
1.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
2.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
3.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
4.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
5.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
Freezer:
1.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
2.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
3.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
4.Standard Fluid Filled__________
Continuous Recording______
Min-Max___________
Dial__________
Digital__________
Other (specify)____________
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).
Refrigerator:
1.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
2.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
3.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
4.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
5.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
Freezer:
1.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
2.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
3.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
4.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
5.Standard Fluid Filled: Yes __________ or No ___________
Continuous Recording: Yes __________ or No ___________
Min-Max: Yes __________ or No ___________
Dial: Yes __________ or No ___________
Digital: Yes __________ or No ___________
Other (specify): Yes __________ or No ___________
14. ! For each refrigerator and freezer indicate how often temperatures are recorded (check all that apply).
Refrigerator:
1.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
2.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
3.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
4.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
5.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
Freezer:
1.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
2.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
3.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
4.Once a day_________
Less than once a day________
Twice a day__________
More than twice a day_________
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 (oC) or Fahrenheit (oF).
Recommended temperature ranges: Refrigerator: (2-8C / 35-46F) Freezer :(-15C / 5F or lower):
Refrigerator (2-8C / 35-46F):
1.Lowest : _________C or _________F
Highest: _________C or _________F
Log available for last 3 months? Yes _________ or No__________
2.Lowest : _________C or _________F
Highest: _________C or _________F
Log available for last 3 months? Yes _________ or No__________
3.Lowest : _________C or _________F
Highest: _________C or _________F
Log available for last 3 months? Yes _________ or No__________
4.Lowest : _________C or _________F
Highest: _________C or _________F
Log available for last 3 months? Yes _________ or No__________
5.Lowest : _________C or _________F
Highest: _________C or _________F
Log available for last 3 months? Yes _________ or No__________
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?
Refrigerator
(2-8C / 35-46F):
1.Below Guidelines________
Above Guidelines________
2.Below Guidelines________
Above Guidelines________
3.Below Guidelines________
Above Guidelines________
4.Below Guidelines________
Above Guidelines________
5.Below Guidelines________
Above Guidelines________
Freezer
(-15C / 5F or lower):
1.Below Guidelines________
Above Guidelines________
2.Below Guidelines________
Above Guidelines________
3.Below Guidelines________
Above Guidelines________
4.Below Guidelines________
Above Guidelines________
5.Below Guidelines________
Above Guidelines________
17. !When the temperatures were outside the recommended range, what action did the clinic/practice take?
(check 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:
Refrigerator
(2-8C / 35-46F):
Freezer
(-15C / 5F or lower):
1.Practice Thermometer:________C or _______F
Reviewer's Thermometer: ________C or _______F
2.Practice Thermometer:________C or _______F
Reviewer's Thermometer: ________C or _______F
3.Practice Thermometer:________C or _______F
Reviewer's Thermometer: ________C or _______F
4.Practice Thermometer:________C or _______F
Reviewer's Thermometer: ________C or _______F
5.Practice Thermometer:________C or _______F
Reviewer's Thermometer: ________C or _______F
20. !Are current temperatures within the guidelines according to the reviewers thermometer?
(Refrigerator: 2-8C / 35-46F, Freezer: -15C / 5F or lower):
Refrigerator:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
Freezer:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
21. ! Is food stored with vaccines in the refrigerator or freezer?
Refrigerator:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
Freezer:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
22. !  Are vaccines stored in the doors of the refrigerator or freezer?
Refrigerator:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
Freezer:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
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?
Refrigerator:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
Freezer:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
24. ! Is there a DO NOT DISCONNECT sign on the refrigerator/freezer electrical outlet?
Refrigerator:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
Freezer:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
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?
Refrigerator:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
Freezer:
1. Yes______ or No________
2. Yes______ or No________
3. Yes______ or No________
4. Yes______ or No________
5. Yes______ or No________
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/ practices 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? (Check one per item)
Required Documentation:
Name of vaccine given: Yes ____________ or No ____________
Date vaccine was given: Yes ____________ or No ____________
Date VIS was given: Yes ____________ or No ____________
Name of vaccine manufacturer: Yes ____________ or No ____________
Lot number: Yes ____________ or No ____________
Name and title of person who gave the caccine: Yes ____________ or No ____________
Address of clinic where vaccine was given: Yes ____________ or No ____________
Publication date of VIS: Yes ____________ or No ____________
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)
Vaccine Administrative Policy
1. How does the clinic/practice offer immunization services to patients?  (Check all that apply)
During well-child visits_________
Walk-in immunizations_________
Off-site immunizations____________
Immunization-only appointments___________
Dedicated days/times for immunizations___________
Other (specify)__________
2. Is an office visit fee charged in addition to any vaccine administration fees?
Yes____________ or No__________
If yes, what is the amount of the office visit fee?_______________
3. Is a physical exam required before immunizations are given?
Yes_____________ or No______________
Assessment of Vaccination Delivery:
4.Does the clinic/practice routinely immunize when the child has:
A cold: Yes________________ No_______________ Situational_________________
Low grade fever (e.g. 100.4F (38C) or lower): Yes________________ No_______________ Situational_________________
Recently been exposed to infectious illness: Yes________________ No_______________ Situational_________________
Mild diarrhea: Yes________________ No_______________ Situational_________________
Convalescing from an acute illness: Yes________________ No_______________ Situational_________________
Effective Communication about Vaccine Benefits and Risks:
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:
6. Does the clinic/practice have a current copy of the following documents?
Recommended Childhood Immunization Schedule:Yes_______________ or No ________________
Revised Standards for Child and Adolescent Immunization Practices:Yes_______________ or No ________________
Contraindications for Childhood Immunization:Yes_______________ or No ________________
Vaccine Management: Recommendations for Handling & Storage of Selected Biologicals:Yes_______ or No_______
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 staff at least once a year________
Distribution of written materials____________
Other (specify)_____________
In-house training by health dept./professional  organization at least once a year_____________
Off-site conferences or workshops at least once a year____________
Web-based training____________
10. Does the practice document ongoing education regarding immunization for persons who administer vaccines and staff who manage or support vaccine administration?
Yes__________or No___________
11. Does the clinic/practice simultaneously administer all vaccines for which the child is eligible?
Yes__________or 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__________or No___________
14. Does the clinic/practice have VAERS forms and know how to report to VAERS?
Yes__________or 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______________
Hepatitis A_____________
Td____________
Measles/Mumps/Rubella____________
Varicella____________
Other (specify)______________
Hepatitis B___________
Influenza____________
Implementation of Strategies to Improve Vaccination Coverage
16. How does the clinic/practice remind patients of their next appointment?  (Check all that apply):
Mail____________
Telephone______________
Verbally at last visit______________
Written appointment slip given at last visit___________
Does not remind patients of next appointment___________
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 immunization/VFC program____________
Yes, by practice staff______________
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______________or No______________
22. What community-based approaches does the clinic/practice use to increase immunization coverage?  (Check all that apply):
No community-based approaches used______________
Provides off-site immunization services____________
Partners schools/school nurses____________
Participates in health fairs_______________
Conducts community-based outreach/education______________
Other (specify)______________
2008 VFC Site Visit  Questionnaire
Final:  December  04, 2007		  Page 1 of 12
http://www.cdc.gov/vaccines/programs/vfc/downloads/2008-vfc-site-visit-questionnaire-508.txt