Read the following instructions carefully

1. Complete the questions below by selecting the root cause or root causes which you think are barriers to patients being vaccinated (multiple selections allowable)
2. Describe any root cause(s) NOT listed in the Other (comment) box if applicable
WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, ETC. IN THIS SURVEY. SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

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* 1. What are (Environment/Places) Facility Specific Barriers that you think contribute to low vaccination rates in your facility? (Select all that apply)

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* 2. What are (People) Patient/Family Related Factors that you think contribute to low vaccination rates in your facility? (Select all that apply)

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* 3. What are (Machine) Organizational/Systemic/Policies Factors that you think contribute to low vaccination rates in your facility? (Select all that apply)

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* 4. What are (Methods) Products/Material Factors that you think contribute to low vaccination rates in your facility? (Select all that apply)

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* 5. Completion of this root cause analysis was easy to do on-line.

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* 7. Provide first and last name of person completing this survey

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* 8. Any additional thoughts or comments you would like to provide about this process?

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* 9. Provide name of facility

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* 10. Provide 6-digit CMS provider number (CCN#, begins with a 45 or 67).

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* 11. What interventions (if any) has my facility implemented to try and resolve some of the issues included in this RCA? Please explain.

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* 12. I have printed a completed copy of this RCA survey with all the answers for my records (right-click over the survey and select "Print")

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