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• MOBI One Month Follow-Up

Fill out this feedback form immediately following your MOBI or TIES training. If you do not receive an email confirmation, your form did NOT submit.

If you are a physician, nurse or health care worker seeking information on a MOBI or TIES training, contact the MOBI/TIES Office.

Project Type * MOBI TIES

Trainer Name *

Trainer Email *

Site Name *

Presentation Date *

Time of MOBI *

121234567891011 : 0030 AMPM

Presentation completed including Q&A *

Yes

No

Total number of attendees *

Number of Physicians

Number of Adv Practice Nurse/PA

Number of Nurses

Number of MA

Number of Other

List questions asked by audience and indicate any needed follow-up

Any slides, material or information to be added or deleted? *

Yes

No

Slides, material or information to be added or deleted

Food/beverage provided? *

Yes

No

Food/beverage provided by

AFIX performed prior to MOBI (or adolescent AFIX for TIES) *

Yes

No

Date AFIX performed

AFIX Planned

Yes

No

Maybe

AFIX planned date

Reason for no planned AFIX

During the MOBI presentation, the practice committed to do the following *

Have an AFIX measurement

Check immunization status at every visit

Give vaccines even if mild illness is present

Give all vaccines that are due

Update policies/procedures to reduce barriers

Institute a reminder/recall system

Sign up and use IMPACT SIIS (Registry)

Other

Does the practice expect you to follow up in one month *

Yes

No

Additional Comments

If you are human, leave this field blank.