2016 Program Planner MOBI & TIES

Program

Department/Organization *

Trainer Name *

Trainer Email *

Has this practice received a MOBI before? *

Yes

Date of Planned Program *

Is this a rescheduled program? *

Yes

Start Time *

Number of Attendees *

Number of Attendee Packs Needed *

If you marked "0" attendee packs, do you want anything mailed to you?

Site Name *

VFC or Assign Number (See the assessment portion of your AFIX 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

Training Location Type *

Location Other

Attendee Representation *

Representation Other

Attendee Specialty *

Specialty Other

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

Pink book needed? (Only for MOBI) *

Yes

Additional Notes: