District XI Immunization Pre-Test Year 2

District XI has been selected through a CDC grant funded to ACOG to participate in a project to increase immunization rates in adults. A total of 15 ob-gyn practices over a three-year period will selected to participate. All sites will receive free training, educational materials, and on-going assistance for specific vaccine-related issues. Please complete this survey if you are interested in participating in Year 2 of this program.

Please note: you do not have to currently offer immunizations to participate, all are welcome to complete the survey.

Question Title

* Does your practice regularly offer any immunizations to adolescent or adult women?

Yes

Question Title

* If yes, please check all of the immunization(s) you provide,

Influenza

Human papillomavirus (HPV)

Hepatitis A

Hepatitis B

Herpes Zoster (shingles)

Tetanus/Diphtheria (Td)

Tetanus/Diphtheria/Pertussis (Tdap)

Measles/Mumps/Rubella (MMR)

Varicella (chickenpox)

Pneumococcal disease

Meningococcal disease

None

Question Title

* Does your practice currently have an immunization coordinator or a specific individual responsible for immunization (a point of contact) for your practice?

Yes

Question Title

* If yes, what position does this person hold?

Office Manager

CNA

APRN

CNM

MD/DO

Other

Question Title

* Has your practice ever contacted the state or local health department's immunization program to inquire about services they provide?

Yes

Question Title

* Does your practice immunize adolescents 18 years old and younger?

Yes

Question Title

* Are you familiar with Texas' Vaccines for Children's Program (VFC)?

Yes

Question Title

* If yes, do you participate in the Vaccines for Children (VFC) program?

Yes

If not, why not?

Question Title

* Does your practice bill any of the following insurers for immunizations using reimbursable codes?

	Yes	No
Private insurance	Private insurance Yes	Private insurance No
Medicaid	Medicaid Yes	Medicaid No
Medicare	Medicare Yes	Medicare No

Question Title

* Did you know that Texas has an immunization registry?

Yes

Question Title

* Is your practice currently participating in the Texas immunization registry?

Yes

Question Title

* Do you have a tracking form or other place in the patient record to record immunizations separately from progress notes?

Yes

Question Title

* Were you aware that ACOG was promoting that ob-gyn practices provide immunizations to women prior to this program?

Yes

Question Title

* Does your practice regularly offer any immunizations to adolescent or adult women?

Question Title

* If yes, please check all of the immunization(s) you provide,

Question Title

* Does your practice currently have an immunization coordinator or a specific individual responsible for immunization (a point of contact) for your practice?

Question Title

* If yes, what position does this person hold?

Question Title

* Has your practice ever contacted the state or local health department's immunization program to inquire about services they provide?

Question Title

* Does your practice immunize adolescents 18 years old and younger?

Question Title

* Are you familiar with Texas' Vaccines for Children's Program (VFC)?

Question Title

* If yes, do you participate in the Vaccines for Children (VFC) program?

Question Title

* Does your practice bill any of the following insurers for immunizations using reimbursable codes?

Question Title

* Did you know that Texas has an immunization registry?

Question Title

* Is your practice currently participating in the Texas immunization registry?

Question Title

* Do you have a tracking form or other place in the patient record to record immunizations separately from progress notes?

Question Title

* Were you aware that ACOG was promoting that ob-gyn practices provide immunizations to women prior to this program?

Question Title

* Please type your name, email address and the name of your practice in the box below.