2017 MnVFC Site Visit Follow-up Form
Original visit date: ____________
Follow-up date: _____________
Date forms sent to MDH: ___________
Site Information
Site name:
MnVFC PIN:
IPI Advisor Information (staff that performed visit)
IPI Advisor:
Phone:
County:
Email:
Follow-up Information
☐ Letter or email (attach to form) ☐ Phone call ☐ In Person Visit (prior approval required for reimbursement)
Unmet requirements and corrective action:
Unresolved issues and plan/timeline for resolution:
Notes:
To be completed by MnVFC clinical coordinator/planner at MDH
Date reviewed:
Signature:
IM M UNI Z A T IO N P RA CT I CE S IM PR OV EM E N T (I P I)
February 2017