2009 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 are required to 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_______ Public clinic non-health dept_____ 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_________ 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. 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 _____; No ______ Proper vaccine storage and handling: Yes _____; No ______ Vaccine shipping (includes receiving, & transport): Yes _____; No ______ Procedures for vaccine relocation in the event of a power failure, mechanical difficulty or emergency situation (emergency plan): Yes _____; No ______ Has the emergency plan been reviewed or updated annually or since change in responsible staff?: Yes _____; No ______ Vaccine ordering: Yes _____; No ______ Inventory control (e.g. stock rotation): Yes _____; No ______ Vaccine wastage: Yes _____; 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*: DTaP (5/17/07) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Polio (1/1/00) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: MMR (03/13/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Hepatitis B (7/18/07) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Varicella (03/13/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Hepatitis A (3/21/06) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Hib (12/16/98) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Pneumococcal Conjugate (9/30/02) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Inactivated Influenza (07/24/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Live Intranasal Influenza (07/24/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Adult Pneumococcal Polysaccharide (PPV23) (7/29/97) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Meningococcal (01/28/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Td/Tdap (11/18/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Rotavirus (08/28/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Human Papillomavirus (2/02/07) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Multiple Vaccine (09/18/08) VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VACCINE*: Other ______________________ VIS VERSION BEING USED IN THIS CLINIC/PRACTICE: Current: ______ Outdated: ______ None Used: ______ Does Not Administer: ______ VIS Website: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-multi.pdf Current VIS publication dates as of 11/28/2008 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? Yes: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Have thermometer but not placed properly: Yes: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. No thermometer: Yes: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. 13. (A) What type of thermometer is used by the clinic/practice (check all that apply)? Standard Fluid Filled: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Continuous Recording: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Min-Max: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Dial: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Digital: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Other (specify): Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. 13. (B) ! For each type of thermometer used by the clinic/practice, indicate if the thermometer is certified (check all that apply). Standard Fluid Filled: Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Continuous Recording: Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Min-Max: Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Dial: Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Digital: Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Other (specify): Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ 14. ! For each refrigerator and freezer indicate how often temperatures are recorded (check all that apply). Once a day: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Less than once a day: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. Twice a day: Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. More than twice a day:Refridgerator: #1. #2. #3. #4. #5. Freezer: #1. #2. #3. #4. #5. 15. !Record the highest and lowest temperatures logged in the last 3 months. If partial log is available for the past three months, record the highest and lowest temperatures from available logs. If no log is available, use current temperature for both lowest and highest temperatures and select no log is available for last 3 months. If practice does not have a thermometer use reviewer's thermometer temperature to record both lowest and highest temperatures. Use same temperatures for reviewer?s section in question #19. If log is available for less than 3 months, use lowest and highest temperatures from timeframe available on log and select partial log is available for last 3 months. All three sections must be answered. Please indicate if recordings are Celsius (°C) or Fahrenheit (°F). Recommended temperature ranges: Refrigerator: (2-8°C / 35-46°F) Freezer :(-15°C / 5°F or lower) Lowest: Refridgerator: #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Freezer: #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Highest: Refridgerator: #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Freezer: #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Log available for last 3 months?: Refridgerator: #1. Yes____ No_____ Partial_____ #2. Yes____ No_____ Partial_____ #3. Yes____ No_____ Partial_____ #4. Yes____ No_____ Partial_____ #5. Yes____ No_____ Partial_____ Freezer: #1. Yes____ No_____ Partial_____ #2. Yes____ No_____ Partial_____ #3. Yes____ No_____ Partial_____ #4. Yes____ No_____ Partial_____ #5. Yes____ No_____ Partial_____ 16. ! During past 3 months or for the amount of time log is available, if less than 3 months, how many times were the temperatures outside the recommended range? If no log is available, select the ?unknown: no log available? answer. Below Guidelines: Refridgerator: (2-8°C / 35-46°F) #1. #2. #3. #4. #5. Freezer: (-15°C / 5°F or lower) #1. #2. #3. #4. #5. Above Guidelines: Refridgerator: (2-8°C / 35-46°F) #1. #2. #3. #4. #5. Freezer: (-15°C / 5°F or lower) #1. #2. #3. #4. #5. Unknown: no log availble: Refridgerator: (2-8°C / 35-46°F) #1. #2. #3. #4. #5. Freezer: (-15°C / 5°F or lower) #1. #2. #3. #4. #5. 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_____ Not applicable, no temperatures outside range_____ Unable to answer, no log available_____ 18. ! Does the clinic/practice have written documentation of the action taken when the temperatures were outside the recommended range? Yes ______ No _______ Not applicable, no temperatures outside range Unable to answer, no log available ______ 19. Record the current temperatures : Practice Thermometer: Refridgerator: (2-8°C / 35-46°F) #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Freezer: (-15°C / 5°F or lower) #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Reviewer's Thermometer: Refridgerator: (2-8°C / 35-46°F) #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°F Freezer: (-15°C / 5°F or lower) #1. _____°C _____°F #2. _____°C _____°F #3. _____°C _____°F #4. _____°C _____°F #5. _____°C _____°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) Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ 21. ! Is food stored with vaccines in the refrigerator or freezer? Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ 22. ! Are vaccines stored in the doors of the refrigerator or freezer? Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ 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? Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ 24. ! Is there a "DO NOT DISCONNECT" sign on the refrigerator/freezer electrical outlet? Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ 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? Refridgerator: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ No_________ Freezer: #1. Yes________ No_________ #2. Yes________ No_________ #3. Yes________ No_________ #4. Yes________ No_________ #5. Yes________ 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% of charts reviewed_______ VFC screening coverage of at least 95% of charts reviewed _______ VFC screening coverage of at least 90% of charts reviewed ________ VFC screening coverage below 90% of charts reviewed _________ 30. What methodology was used to determine VFC eligibility screening coverage during this site visit? CDC-supplied Lot Quality Assurance (LQA) 30 chart protocol_________ CoCASA__________ Grantee-developed methodology________ Other: ___________________________ 31. Do all immunization records contain the following documentation required by statute 42 US Code 300aa-25 and 300aa-26? ( one box per item) Required Documentation: Name of vaccine given Yes______ No______ Required Documentation: Date vaccine was given Yes______ No______ Required Documentation: Date VIS was given Yes______ No______ Required Documentation: Name of vaccine manufacturer Yes______ No______ Required Documentation: Lot number Yes______ No______ Required Documentation: Name and title of person who gave the vaccine Yes______ No______ Required Documentation: Address of clinic where vaccine was given Yes______ No______ Required Documentation: Publication date of VIS Yes______ 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 _________ 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 4. Does the clinic/practice routinely immunize when the child has: A cold: Yes ______ No _______ Situational _____ Low grade fever (e.r. 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_______ No______ Revised Standards for Child and Adolescent Immunization Practices Yes_______ No______ Contraindications for Childhood Immunization Yes_______ No______ Vaccine Management: Recommendations for Handling & Storage of Selected Biologicals Yes_______ 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 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 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)________ 2009 VFC Site Visit Questionnaire December 30, 2008 Page 1 of 12 This document can be found on the CDC website at: http://www.cdc.gov/vaccines/programs/vfc/downloads/2009-vfc-site-visit-question.txt