Summit Survey

1. Approximately how many children age 35 months and younger do you see in your practice? What percent of your total practice is this?

Approximately how many children age 35 months and younger do you see in your practice? What percent of your total practice is this? # of children
% of practice

2. Do you believe there is an issue of under immunization for children in St. Joseph County? (Where under immunization means a child has not completed the following series of immunizations: 4 Dtap, 3 Polio, 3 Hep B and 1 MMR by 35 months of age.)

Do you believe there is an issue of under immunization for children in St. Joseph County? (Where under immunization means a child has not completed the following series of immunizations: 4 Dtap, 3 Polio, 3 Hep B and 1 MMR by 35 months of age.) Yes

No

3. Do you provide children's immunizations at your practice?

Do you provide children's immunizations at your practice? Yes

No

4. If you answered yes to the previous question, please select those you provide (select all that apply)

If you answered yes to the previous question, please select those you provide (select all that apply) VFC (Vaccine for Children)

Private

State-funded vaccine

5. What are the key barriers to immunizations in your practice? Please select the top three that apply:

What are the key barriers to immunizations in your practice? Please select the top three that apply: Inconsistent vaccine supply

Parent concerns related to vaccine safety and/or autism

Inaccurate public knowledge for immunizations of infants

Federal restrictions on vaccines under 317 funding that limit their use to public health clinics only

Transient Medicaid population with multiple changes in managed care organization

Private insurance plans not covering vaccines

Other (please specify)

6. Have you seen an increase in the number of people refusing vaccines?

Have you seen an increase in the number of people refusing vaccines? Yes

No

7. If you answered yes to the previous question, please select the two most frequent reasons you hear for refusal of vaccines:

If you answered yes to the previous question, please select the two most frequent reasons you hear for refusal of vaccines: Autism concerns

Vaccine safety

Religious objections

Other (please specify)

8. Do you utilize a reminder/recall system for immunizations? Please select all that apply:

Do you utilize a reminder/recall system for immunizations? Please select all that apply: Phone

Mail

E-Mail

Do not use reminder/recall

Other (please specify)

9. Do you use CHIRP (Children & Hoosiers Immunization Registry Program)?

Do you use CHIRP (Children & Hoosiers Immunization Registry Program)? Yes

No

10. If you answered no to the previous question, please briefly explain why:

If you answered no to the previous question, please briefly explain why:

11. Has your office or support staff received continuing education/training in any of the following areas? Please select all that apply:

Has your office or support staff received continuing education/training in any of the following areas? Please select all that apply: Proper vaccine storage and handling

CDC education modules for childhood immunizations

Comprehensive training for utilizing the CHIRP database

Other immunization-related training (please specify):

*

12. Please tell us about yourself:

Please tell us about yourself: Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:

1. Immsummit Survey

1. Approximately how many children age 35 months and younger do you see in your practice? What percent of your total practice is this?

2. Do you believe there is an issue of under immunization for children in St. Joseph County? (Where under immunization means a child has not completed the following series of immunizations: 4 Dtap, 3 Polio, 3 Hep B and 1 MMR by 35 months of age.)

3. Do you provide children's immunizations at your practice?

4. If you answered yes to the previous question, please select those you provide (select all that apply)

5. What are the key barriers to immunizations in your practice? Please select the top three that apply:

6. Have you seen an increase in the number of people refusing vaccines?

7. If you answered yes to the previous question, please select the two most frequent reasons you hear for refusal of vaccines:

8. Do you utilize a reminder/recall system for immunizations? Please select all that apply:

9. Do you use CHIRP (Children & Hoosiers Immunization Registry Program)?

10. If you answered no to the previous question, please briefly explain why:

11. Has your office or support staff received continuing education/training in any of the following areas? Please select all that apply:

12. Please tell us about yourself: