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AFIX Site Visit Questionnaire

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General Notes

Questionnaire may be filled out prior to the AFIX visit or during the visit. The assessor, along with the provider, should select 2-3 strategies to incorporate into the QI plan for implementation and follow-up

  • If questionnaire is filled out during the visit and using CoCASA, the provider’s demographic information should be entered in the provider set-up tab
  • If questionnaire is filled out during the visit and using AFIX online tool, the provider’s demographic information should be entered in the General Site Visit Information tab
  • If questionnaire is mailed out prior to the AFIX visit, the following provider demographic questions should be added to the top:
    • Assessment date:
    • Assessment name:
    • Assessor’s name:
    • Provider site name:
    • Provider address:
    • Contact person:
    • Telephone/fax:
    • E-mail:
    • VFC pin number:
    • Type of medical records the provider uses: Electronic (type); OR Paper
    • Method of reporting to the IIS:


Strategies to Improve the Quality of Immunization Services

  1. Do you have a reminder/recall process in place for pediatric/adolescent patients? (y/n)
  2. Do you offer walk-in or immunization only visits? (y/n)
  3. Do you routinely measure your clinic’s pediatric/adolescent immunization coverage levels and share the results with your staff? (y/n)
  4. Do you schedule the next vaccination visit before the patients/parents leave the office? (y/n)
  5. Do you contact patient/parents within 3-5 days when a "well child" or “immunization only” visit is a "no show" and reschedule it for as soon as possible? (y/n)
  6. Do you have a system in place to schedule wellness visits for patients at 11-12 years of age? (y/n)
  7. Do you have an immunization champion at this practice that focuses on QI measures, reducing barriers, and improving coverage levels? (y/n)
  8. Do you regularly document vaccine refusals and reasons for refusals (parent choosing to delay, parent has vaccine safety concern, medical contraindication, etc.)? (y/n)
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Strategies to Decrease Missed Opportunities

  1. Does your immunization staff educate parents about immunizations and the diseases they prevent, even when the parents refuse to immunize? (y/n)
  2. Do you have immunization information resources to help answer questions from patients/parents? (y/n)
  3. Is your immunization staff knowledgeable and comfortable with current ACIP recommendations, including minimum intervals, contraindications, etc.? (y/n)
  4. Do you train front desk/scheduling staff so they know when it’s appropriate to schedule immunization appointments? (y/n)
  5. Do you have standing orders for registered nurses, physician assistants, and medical assistants to identify opportunities to administer all recommended pediatric/adolescent vaccines? (y/n)
  6. Is your immunization staff knowledgeable and comfortable with administering all recommended vaccinations to patients at every visit? (y/n)


Strategies to Improve Completeness and Accuracy of Immunization Information in the IIS

  1. Does your staff report all immunizations you administer at your clinic (or practice) to your state/city IIS? (y/n)
  2. Does your staff report immunizations previously administered to your patients by other providers to the IIS (e.g., official shot record, other IIS report, copy of medical record)? (y/n)
  3. Do you inactivate patients in the IIS who are no longer seen by your practice? (y/n)
  4. Do you use your IIS to determine which immunizations are due for each patient at every visit? (y/n)
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