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 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 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): 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: (2-8°C / 35-46°F) Freezer :(-15°C / 5°F or lower): Refrigerator (2-8°C / 35-46°F): 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 (2-8°C / 35-46°F): 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 (-15°C / 5°F 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 (2-8°C / 35-46°F): Freezer (-15°C / 5°F 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 reviewer’s thermometer? (Refrigerator: 2-8°C / 35-46°F, Freezer: -15°C / 5°F 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/ 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? (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. 100.4°F (38°C) 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