2020 Program Planner – MOBI TIES

Package Mailed (Office Use Only)

Program

Date of Planned Program: *

If this date is less than TWO WEEKS from now, contact Lory Winland at lwinland@ohioaap.org to alert her after completing your Program Planner. If this is a rescheduled program, do not fill out a new program planner, go into completed forms and update the form.

Time of Training (if known)

Department/Organization *

Trainer Name *

Trainer Email *

Number of Attendees *

Number of Attendee Packs Needed *

If 0 attendee packs, do you need anything sent to you?

Are the packets/resources sent directly to the physician office/training location? *

Yes

No, please send them to me at the local health department

Site Name *

VFC or Assign Number (See the assessment portion of your IQIP Manual) *

Multiple Practices Attending

Yes

List Practices Attending

Site Street Address *

Site City *

Zip Code *

Site County *

Site Contact *

Site Phone Number *

Site Contact Email Address *

Choose the MOBI Modules, in addition to the MOBI Core Module? (choose 1-2) (Only for MOBI)

Vaccine Administration 101

MOBI Resources in Depth

Vaccine Hesitancy Strategies

MOBI Advanced

Clinical Disease Slides

Don't know yet

Reminder/Recall

MOBI: Your box comes with the following items. Check all that you want to be included: *

Pink Book

Vaccines and Your Child (yellow Paul Offit booklet)

Parental refusal brochures

DTaP Reminder Postcards

DTaP Drop-Off Toolkit (booklet ONLY)

No resources needed at this time

MOBI: What is your total number of unique patients ages 0-24 months?

MOBI: Is there anything else, or anything extra, you would like in your box?

TIES: Your box comes with the following items. Check all that you want to be included: *

HPV Reminder Postcards

Adolescent Vaccine Recall Postcards

HPV Pamphlets

Immunization Flip Chart (English) (limited supply)

Immunization Flip Chart (Spanish)

Immunization Flip Chart (Chinese)

No resources needed at this time

TIES: What is your total number of unique patients ages 11-21 years?

TIES: Is there anything else, or anything extra, you would like in your box?

What percentage of your patient population is Medicaid?

Additional Notes: