2020 Trainer Feedback/Program Completion Form MOBI/TIES Packet Received - Date Recorded (Office Use Only) Program * MOBI TIES Trainer Name * Local Health Department * (Choose One) Allen Co Health Department Alliance City Health Department Ashtabula County Health Department Auglaize County Health Department Belmont County Health Department Butler County Health Department Canton City Health Department Carroll County General Health District Champaign County Health District Cincinnati Health Department Cincinnati TruStaff City of Cleveland Health Department City of Hamilton Health Department Clark County Combined Health District Clermont County General Health District Columbiana County Health Department Columbus Public Health Crawford County Health Department Cuyahoga County Board of Health Darke County Health Department Defiance County General Health District Delaware General Health District Erie County Health Department Fairfield Dept. of Health Franklin County Public Health Fulton County Health Department Galion City Health Department Gallia County Health Department Geauga County Health District Greene County Combined Health District Hamilton City Health Department Hancock County Health Department Henry County Health Department Hocking County Health Department Holmes County Health Department Jackson County Health Department Jefferson County Health Department Knox County Health Department Lake County General Health District Lawrence County Health Department Licking County Health Department Logan County Lorain County General Health District Madison County-London City Health District Mahoning County District Board of Health Mansfield Ontario Richland County Health Department Marion Public Health Department Medina County Health Department Mercer County Celina City Health Department Miami County Public Health Monroe County Health Department Morrow County Health District Noble County Health Department Niles City Health Department Ohio Chapter, AAP Ohio Department of Health Ottawa County Health Department Portage County Health Department Preble County General Health District Dayton/Montgomery County Public Health Putnam County Health Department Ross Co General Health District Sandusky County Health Department Seneca County General Health District Sidney-Shelby County Health Department Stark County Health Department Summit County Public Health Toledo-Lucas County Health Department Trumbull County Health Department Tuscarawas County Health Department Van Wert County Health Department Warren City Health Department Wayne County Health Department Williams County Health Department Wood County Health District Wyandot County Health Department Zanesville Muskingum County Health Union County Health Department Trainer Email * Site/Practice Name * VFC or Assign Number (See the assessment portion of your IQIP Manual) Presentation Date * Date of Previous MOBI or TIES Presentation County Total number of attendees * How many physicians? How many others? Did you perform an AFIX or IQIP assessment prior to the MOBI or TIES program? * Yes No If yes, date of the feedback session: If no, is one planned at a later date? Yes No Maybe IQIP planned date Reason for no planned IQIP Additional Comments If you are human, leave this field blank.
