Sample VFC Provider Feedback Survey

We’d love to hear what you think about the Vaccines for Children program.  Please take a minute to complete the following survey.  Your answers will help us improve the program to serve both you and our children better. 

Provider/Clinic Name:   _______________________________  	Type of Practice: 	 Private Solo Practice  		 Private Group Practice	
  Federally Qualified Health Center/Rural Health Center	
 Health Department Clinic 	  Other:___________________

Practice Specialty Type: Pediatrics     Family practice    Internal Medicine     Multispecialty	 Health Department Clinic   Other: ___________________

Address:   _________________________________________________________________________________________________________
Street							City				County			Zip Code

Telephone Number:   _________________________________________ 		E-Mail: __________________________________________________________

Person Completing the Survey:   ____________________________________    Title:   __________________________________________	
        
WE WANT TO KNOW WHAT YOU THINK ABOUT THE VFC PROGRAM.						Very 			        	Very 
PLEASE RATE YOUR EXPERIENCE FOR  QUESTIONS 1 - 9 USING THE SCALE FROM 1 TO 5.			Satisfied		       	 Dissatisfied
      							
1.  The support, information and materials provided by state/local VFC program staff.					1	2	3	4	5 	NA

2.  The ease of screening patients for VFC-eligibility.									1	2	3	4	5	NA

3.  The ease of VFC record keeping.										1	2	3	4	5	NA

4.  The ease of using the VFC vaccine ordering system.								1	2	3	4	5	NA

5.  The timeliness of VFC supplied vaccine delivery.									1	2	3	4	5	NA

6.  The condition of VFC supplied vaccine at delivery.								1	2	3	4	5	NA

7.  The decreased need to refer children to public clinics for immunizations.						1	2	3	4	5	NA

8.  The merit of the VFC vaccine accountability system ( reporting the number of doses administered, benchmarking, etc.)	 	1	2	3	4	5	NA

9.  Overall satisfaction with the VFC program									1	2	3	4	5	NA

10.   The range of vaccine brand choice available for VFC vaccines							1	2	3	4	5	NA

11.  Which vaccines are routinely recommended in this practice/clinic? (Please check all that apply)	 DTaP			MMR	
 Hepatitis A		 Pneumococcal 	
 Hepatitis B		 Polio
 Hib			 Varicella
 HPV			 Influenza
 Meningococcal	 Rotavirus
 Others:________________________

12a.	Does this practice/clinic have a systematic way to identify and recall children in need of vaccinations?	 Yes	 No
12b.	If yes, what kinds of system do you use?	 recall system, computerized
 recall system, tickler file
 registry
 periodic chart reviews
 other:________________________________________________

13a.	Have immunization coverage levels  been assessed in your practice within the last year?     Yes       No	
13b. 	If yes, by whom?	 Own practice/clinic staff		 State health department staff
 Local health department staff	 MCO staff
13c.	If yes to 13a., what assessment tool was used?  CoCASA    Other:________	 Do not know
13d.  	If yes to 13a., what age & series was assessed? _______________
13e.     If yes to 13a, what was the coverage level _________%

14. 	 Does this practice/clinic participate in a state/local immunization registry?		 Yes	 No	

15.	      What recommendations do you have for improving the VFC program in (specify state)? ______________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Please fax or mail your completed form to:		Your Health Department's Name
Attn: VFC Program
Street Address
City, State, Zip 
Telephone: (      )   ________________________	Fax:	(      )   ________________________