Immunization Resources – 3 Month Survey Site Name * Site Street Address * Site City * Zip Code * Site County * Site Contact * Site Phone Number * Site Contact Email Address Have you had a Maximizing Office Based Immunization (MOBI) or Teen Immunization Education Sessions (TIES) training in the past 12 months? Yes, MOBI in the past 12 months Yes, TIES in the past 12 months Yes, both a MOBI and TIES in the past 12 months No, but I did receive immunization resources Enter the MOBI (childhood vaccine) resources you received from the Ohio AAP. Check all that apply. If you are unsure of which resources you received, you may view images by clicking here. Epidemiology and Prevention of Vaccine-Preventable Diseases ("The Pink Book") Vaccines and Your Child by Paul Offit, MD, FAAP Childhood Vaccination Brochures DTaP Reminder Postcard MOBI Attendee Packet (teal folder) Enter the TIES (adolescent vaccines) resources you received from the Ohio AAP. Check all that apply. If you are unsure of which resources you received, you may view images by clicking here. HPV Reminder Magnet Adolescent Vaccines Recall Postcard HPV Reminder Postcard HPV Vaccine Brochures TIES Attendee Packet (green folder) Have you used the Pink Book? Yes No No, but I plan to Please rate the effectiveness of "The Pink Book" in providing you comprehensive information on routinely used vaccines and the diseases they prevent. "1" is NOT effective and "7" is VERY effective. 1 2 3 4 5 6 7 Have you used the "Vaccine Safety and Your Child" by Paul Offit, MD, FAAP? Yes No No, but I plan to Please rate the utility of "Vaccine Safety and Your Child" in providing general vaccine information for your patients. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the Childhood Vaccination Brochures? Yes No No, but I plan to Please rate the utility of Childhood Vaccination Brochures in providing supplemental information during conversations with parents. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the DTaP Reminder Postcards? Yes No No, but I plan to Please rate the utility of the DTaP Reminder Postcards in getting parents to make an appointment for the 4th dose of DTaP. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the HPV Reminder Magnets? Yes No No, but I plan to Please rate the utility of the HPV Reminder Magnets in getting patients to return for the 2nd and 3rd HPV dose. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the Adolescent Vaccines Recall Postcard? Yes No No, but I plan to Please rate the utility of Adolescent Vaccines Recall Postcard in getting parents or patients to make an appointment for adolescent vaccines. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the HPV Reminder Postcards? Yes No No, but I plan to Please rate the utility of HPV Reminder Postcards in getting parents or patients to make an appointment for the HPV vaccine. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the HPV Vaccine Brochures? Yes No No, but I plan to Please rate the utility of HPV Vaccine Brochures in providing supplemental information during conversations with parents and patients. "1" is NOT useful and "7" is VERY useful. 1 2 3 4 5 6 7 Have you used the MOBI Attendee Packet? Yes No No, but I plan to Please rate your overall satisfaction with the MOBI Attendee Packet in providing you additional information on childhood immunizations. "1" is NOT satisfied and "7" is VERY satisfied. 1 2 3 4 5 6 7 Have you used the TIES Attendee Packet? Yes No No, but I plan to Please rate your overall satisfaction with the TIES Attendee Packet in providing you additional information on adolescent immunizations. "1" is NOT satisfied and "7" is VERY satisfied. 1 2 3 4 5 6 7 Please send me information about receiving a MOBI or TIES presentation! Yes please! No, thank you! Enter your email address: Please enter any additional notes you would like to share.
