Survey of Maryland Pharmacists Vaccine Administration, December 2009- Corporate Pharmacy Edition

1. PHARMACIST IMMUNIZATION SURVEY

Dear Chain Pharmacy Permit Holder:

In order to demonstrate the value of pharmacists certified to administer vaccines in Maryland, the Maryland Board of Pharmacy is collecting monthly statistics about immunization efforts through this survey. Please take a few minutes to provide monthly statistics regarding the number, type and primary location where your company has administered vaccines. If you are answering on behalf of an entire pharmacy, please inform your pharmacists that you will be answering for them and they do not need to complete the survey as well.

Individual survey responses are confidential and will be aggregated in monthly Board reports for use in analyzing pharmacists' contributions to State efforts to immunize Maryland citizens. The results will be provided to key personnel at the State Department of Health and Mental Hygiene. This survey will continue through March 2010 and you will be sent a reminder request at the beginning of each month to provide the previous month's information. Thank you very much for your assistance.

1. Please indicate the name of the pharmacy completing this form:

Please indicate the name of the pharmacy completing this form: Name:

2. How many influenza vaccines did your pharmacists administer in each region in December 2009?

How many influenza vaccines did your pharmacists administer in each region in December 2009? Baltimore Metropolitan (Baltimore City and Counties of: Anne Arundel, Baltimore, Carroll, Harford, and Howard)
Washington Suburbs (Counties of: Frederick, Montgomery, and Prince Georges)
Southern Maryland (Counties of Calvert, Charles, St. Mary's)
Eastern Shore (Counties of Caroline, Cecil, Dorchester, Kent, Queene Anne's, Somorset, Talbot, Wicomic, and Worchester)
Western Maryland (Counties of Allegany, Garrett, Washington)
Total influenza vaccines administered:

3. How many pneumococcal pneumonia vaccines did your pharmacists administer in each region in December 2009?

How many pneumococcal pneumonia vaccines did your pharmacists administer in each region in December 2009? Baltimore Metropolitan (Baltimore City and Counties of: Anne Arundel, Baltimore, Carroll, Harford, and Howard)
Washington Suburbs (Counties of: Frederick, Montgomery, and Prince Georges)
Southern Maryland (Counties of Calvert, Charles, St. Mary's)
Eastern Shore (Counties of Caroline, Cecil, Dorchester, Kent, Queene Anne's, Somorset, Talbot, Wicomic, and Worchester)
Western Maryland (Counties of Allegany, Garrett, Washington)
Total pneumococcal pneumonia vaccines administered:

4. How many herpes zoster vaccines did your pharmacists administer in each region in December 2009?

How many herpes zoster vaccines did your pharmacists administer in each region in December 2009? Baltimore Metropolitan (Baltimore City and Counties of: Anne Arundel, Baltimore, Carroll, Harford, and Howard)
Washington Suburbs (Counties of: Frederick, Montgomery, and Prince Georges)
Southern Maryland (Counties of Calvert, Charles, St. Mary's)
Eastern Shore (Counties of Caroline, Cecil, Dorchester, Kent, Queene Anne's, Somorset, Talbot, Wicomic, and Worchester)
Western Maryland (Counties of Allegany, Garrett, Washington)
Total herpes zoster vaccines administered:

5. Did you have to cancel or end any immunization clinics early for any reason this year?

Did you have to cancel or end any immunization clinics early for any reason this year? Yes, we canceled clinics because we were unable to acquire enough vaccine

Yes, we ended clinics early because we did not have patient demand

No, we were able to complete all immunization clinics as scheduled

Other (please specify other reasons for canceling)

6. Please indicate your email address and your business phone number.

Please indicate your email address and your business phone number. Email Address:
Phone Number: