2017 MnVFC Pre-Visit Worksheet
Site name:
MnVFC PIN:
Address:
Medical director:
Email:
Immunization manager:
Phone:
Email:
Vaccine coordinator:
Phone:
Email:
Vaccine coordinator back-up:
Email:
IPI Site Visit Preparation Checklist
The staff listed have completed the MnVFC online training and printed a certification of completion
Immunization Manager
Vaccine coordinator
Vaccine coordinator back-up
Have a copy of the most recent provider agreement
Check if the above listed staff have changed since the provider agreement was completed
Check all of the vaccines administered at your site, and list the corresponding publication date for each VIS you give to patients.
DTaP _____________
Hepatitis A _____________
Hepatitis B _____________
Hib _____________
HPV _____________
Influenza _____________
MCV4 _____________
MMR _____________
MMR-V _____________
PCV13 _____________
Polio _____________
Rotavirus _____________
Tdap _____________
Varicella _____________
Non-Routine Vaccines:
Men B__________
PPSV23 _____________
Td _____________
Vaccine administration fee charged for MnVFC eligible children is: $
Have a Vaccine Management and Emergency Plan that has been reviewed and dated within the last year
Have the borrowing reports, if applicable, for the last 12 months available at the visit
Have an anaphylaxis protocol that is clearly posted and reviewed annually
Indicate the number of storage units that store vaccine at this location:
# Refrigerators:
# Freezers:
Gather the certificate of calibration testing for all of your temperature monitoring devices
List expiration dates for temperature monitoring devices:
Have temperature logs for the last three months for each vaccine storage unit
Have a back-up thermometer and corresponding current certificate of calibration testing
Identify the circuit breaker for each storage unit (will need access to this during the visit)
Have billing staff available in person or by phone during the visit
Do you have guest WiFi/internet access I can use?
IMMUNIZATION PRACTICES IMPROVEMENT (IPI)
Yes
No If so, what is the password:
February 2017