The Maine Immunization Program would like to gather information from you about how COVID-19 response has impacted your clinic and its services. Please fill out this survey below. It should take no longer than 5-10 minutes. This survey is for informational uses only. Your responses will be confidential and information you share will not impact your participation in the VFC program. We appreciate you taking the time to fill out this survey.

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* 1. Name

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* 2. Clinic Name

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* 3. Clinic's VFC PIN

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* 4. Your job title at your clinic

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* 5. Is this a primary care site?

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* 6. What is your patient population (choose only one)?

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* 7. Have you modified your clinic’s operations to adapt to the coronavirus pandemic? By "operations" we mean hours of operation, limiting certain services, decreased staff hours, etc.

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* 8. Please check any of the following suggested modifications that you have implemented in your practice(s).

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* 9. If you have closed your clinic permanently or temporarily, have you moved your vaccine?

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* 10. Has the clinic had trouble maintaining staffing since the pandemic began?

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* 11. In response to the pandemic, has the clinic made changes in its immunization workflow to emphasize or de-emphasize immunization opportunities?

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* 12. If yes, what are those changes?

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* 13. At this time, do staff routinely discuss immunizations that are due or overdue with patients at sick patient visits?

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* 14. Has time that was formerly devoted to managing the clinic’s immunization program been diverted to the coronavirus response?

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* 15. We are aware that many jobs have shifted. Has the person in charge of immunization changed recently? If so, please add the email address of the new person(s) in charge here.

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* 16. For patients that fall behind on immunizations during the pandemic, does the clinic have a plan for contacting patients and catching them up once circumstances allow?

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* 17. What are services or allowances that the Immunization Program could provide that would help support your clinic through this pandemic? Please let us know if you need to move your vaccine so it is being monitored. We are happy to help you come up with a plan.

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* 18. Is there anything else you would like to share regarding vaccines, the Immunization Program or your immunization practice? If you do not receive our program updates, monthly newsletter and other communications through our listserv, please add your email below. If you would like for us to reach out to you, please enter your contact info below.

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