* 1. Please provide the following information:

* 2. Provider Type

The following evaluation form will be used to better understand how well the Arizona Immunization Program field staff members work with their assigned VFC Program providers. The results of this feedback questionnaire are kept confidential and will be used as part of an overall measurement for field staff members' annual performance evaluations and to identify opportunities for improvement.

* 5. Please evaluate the performance of the VFC Representative based on the following criteria.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
VFC representative arrived on time.
VFC Representative was professional and appropriately dressed.
VFC Representative was prepared and organized.
VFC Representative was knowledgeable about all VFC policies and procedures.
VFC Representative discussed vaccine storage and handling.
VFC Representative is accessible to me by telephone, email, and in person when I need advice of assistance.
I have confidence in the professional advice and recommendations I receive from my VFC Representative.

* 6. Please provide any additional comments: