Project Notification Survey

The purpose of this questionnaire is to gather and assess baseline awareness of some key topics for the group of focus facilities in this project. Answers provided here will be kept anonymous. This survey should take 10 minutes or less to complete. Warning: Do not include patient specific information due to confidentiality purposes. Violations will trigger a security incident that will be reported to CMS.

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* 1. Please enter your facility's 6 digit CMS provider number (usually begins with 45 or 67).

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* 2. Please enter the name of your facility

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* 3. Please enter your contact information

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* 4. Please enter your first, last name, and title

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* 5. Please enter your email address.

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* 6. What do you think may cause your facility to have low vaccination rates?

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* 7. Is there a variation on Hepatitis B (HBV) dosages in your facility?

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* 8. If yes to question #7, explain the variation on dosages (i.e., vaccination schedules, amount given, manufacturers, brand names)

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* 9. Does your facility have a dedicated vaccinations manager?

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* 10. If yes to Question #9, please provide their name and contact information in the comment box.

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* 11. Does your facility administer booster shots for patients who have received one series but still have hepatitis B antibodies = or <10?

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* 12. Does your facility offer Pneumococcal Pneumonia PCV13 and/or PPSV23 vaccines? Check all that apply.

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* 13. Does your facility currently have a vaccination tracking system or vaccination log in place?

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* 14. If yes to question #13, what kind of tracking process/system do you use?

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* 15. Does your facility currently have an active facility patient representative (FPR)?

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