2017 MOBI TIES One Month Survey Program * MOBI TIES Who is filling out this form? * MOBI/TIES Trainer Practice/Department Staff Trainer Name * Trainer Email * Site Name * VFC or Assign Number * Presentation Date * Date of follow-up * Name and title of practice staff person providing information Did the person attend the presentation? (to ensure the highest quality of results, the person answering these questions should have attended the training) * Yes No What change did the practice commit to on their PDSA worksheet? Did the practice return their PDSA Worksheet to the trainer? * Yes No Please ask them to fax the form to the trainer or the Ohio AAP office (614) 846-4025. BEST PRACTICES FOR OFFICE OPERATIONS 1. Did the practice have an AFIX measurement before the presentation? * No Will consider Interested Not enough children or adolescents Yes Can the practice expand on their decision not to have an AFIX measurement? Provide them with information on getting an AFIX. Are they willing to share their AFIX rate with us so we can assist in helping them improve their rates? 2. Is the practice a Vaccines for Children (VFC) provider. Yes No Is there anything else the MOBI/TIES Program could do to improve this? 3. How often does the practice provide a current Vaccine Information Statement (VIS) to parents prior to an immunization? * Never Rarely Sometimes Frequently Almost Always Is there anything the MOBI/TIES office could do to improve this? (Reinforce that it is Federal Law to provide VIS for every immunization) 4. Has the practice updated their written plan for protecting vaccines in case of a power outage since the training? * Yes No Don't have a policy If yes, when was it last updated and how frequently does this normally occur? If the practice does not have a policy, please answer why? 5. Does the practice use the ImpactSIIS Registry? * Yes No No, but wants to start Don't know Is there anything else the MOBI/TIES office could do to improve this? 6. How often does the practice check immunization status at every visit? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? 7. How often does the practice have materials available to address vaccine concerns? * Never Rarely Sometimes Frequently Almost Always Is there anything the MOBI/TIES office could do to improve this? BEST PRACTICES FOR INCREASING VACCINE RATES 8. How often does the practice use an immunization REMINDER system? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? 9. How often does the practice use an immunization RECALL system? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? 10. Does the practice have a "go to" person for vaccine questions? Yes No Is there anything else the MOBI/TIES office could do to improve this? 11. How often does the practice give all vaccines that are due, regardless of the number of injections? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office can do to improve this? 12. How often does the practice allow shots to be given to children or adolescents with minor illnesses like colds, diarrhea or low-grade fever? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? 13. How often does the practice allow patients to come in the for immunization-only nurse visits? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? 14. How often does the practice give age-appropriate vaccines even when no vaccine record is available? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? 15. How often does the practice use combination vaccines? * Never Rarely Sometimes Frequently Almost Always Is there anything else the MOBI/TIES office could do to improve this? VACCINE OBSTACLES 16. What would the practice say are the biggest obstacles to increasing your immunization coverage rates? (check all that apply) Time commitment Cost Staffing Parental Refusal No same-day immunization-only visits Nurses not authorized to immune if due Physician's decision I don't know N/A - we have incorporated the strategy(yes) into our practice Other Please include any other comments here. If you are human, leave this field blank.
