DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention (CDC)

Atlanta, GA 30341-3724

June 2, 20xx

<Name>, MD, Acting Program Manager

State X Immunization Program
Address
City, State, Zip Code
Re: awardee number X X X X X

Dear Dr. <name>:

Enclosed please find the technical assistance site visit report for State X's
immunization program site visit conducted March xx -xx, 20xx.

I want to thank you and your staff members for taking the time to discuss in great length all of the
aspects of your program. It was a pleasure to meet you, and I always enjoy my time with the staff
there and the important work being accomplished.

As you know, the purpose of the technical assistance site visit is to discuss program updates
since the previous site visit, to assess progress toward implementing recommendations made
during the previous site visit, and to provide additional recommendations on intervention
strategies to improve program performance. The visit also provides an opportunity to provide
technical assistance with preparing for and meeting the next cooperative agreement application
requirements.

After reviewing the report, please submit a response addressing any recommendations made
during the visit within thirty (30) days after receipt of this report using the template provided at
the end of the report. I hope that you will find the recommendations in this report useful. Feel
free to call me at (404)639-xxxx or email me @cdc.gov if you have any questions about this
report. Again, thank you for this opportunity.

Sincerely,

Project Officer
Program Operations Branch, Immunization Services Division National
Center for Immunization and Respiratory Diseases Centers for Disease
Control and Prevention
 20xx SITE VISIT REPORT FOR STATE X
Year Two of 20xx-20xx Cooperative Agreement
Immunization Services Division
Program Operations Branch

Site Visit Date(s): Began: Ended:

Date Report Prepared:

I
Awardee: State X
I
Recipients' Names: Principal Investigator (PI): <name>:
Immunization Program Manager:
<name>:
Others: Click here to enter text.
Grant Number: XXXXXX

Project Officer: <name>

Purpose of Visit:
The purpose of the 2014 site visit is to follow-up on past issues and recommendations, confirm continued progress
and fulfillment of the cooperative agreement objectives, and to provide consultation and assistance concerning
programmatic and technical matters.
Awardee Participants:
<name>, Chief, Immunization Branch
<name>, Chief, Field Services Section
<name>, Public Health Medical Officer
<name>,Adult Immunization Coordinator
<name>,Chief, Information & Education Section
<name>,Chief, Registry and Immunization Rate Assessment Section
<name>, Population Assessment Coordinator
<name>, Epidemiologist, Surveillance Supervisor
<name>, Epidemiologist, Surveillance and Control Unit Supervisor
<name>, Project Assistant
<name>, Research Assistant
<name>, Analyst II
<name>, Medical Officer
<name>,Central VFC Operations Coordinator
<name>, Quality Assurance Coordinator <name>, Field Representative

CDC Participants:
<name>,Field-Assigned Public Health Advisor
<name>, Field-Assigned Public Health Advisor
<name>, Project Officer
<name>, Medical Epidemiologist
<name>, IISSB Consultant

1
Key Items and Updates Discussed: (This section highlights updates from the previous report and is intentionally brief. For a complete
description of the work of this awardee, please reference last year’s report.)

Section I: Program Management

(eGrATIS Unit A Objectives)

There are three state positions and 11contracted positions that are currently vacant. The vacant state positions include the Assistant
Branch Chief, a Staff Services Manager and an Associate Governmental Program Analyst. Contracted vacancies include two
Health Educators, Perinatal Hepatitis B Coordinator, four Clerks, Data Exchange/Transfer Specialist, two Web Developers, and
one Field Representative. All are being recruited for or are in the hiring process. Regarding the other areas of Program
Management: the awardee is making adequate progress in this area according to the requirements of the cooperative agreement.

Section II: Program Evaluation

(eGrATIS Unit 85 Objective)

Please describe the members of the Immunization Program Evaluation (IPE) team and their roles.
<name>:Chief of Information and Education, workgroup member. Supervises the creation of all health education materials.

<name>: Chief of Field Services ,Acting Assistant Branch Chief. Serves as overall lead of project. Establishes workgroup,
coordinates meetings and submits required reports.

<name>: Chief of Vaccine Management and VFC Program, workgroup member. Serves as storage and handling
SME.

<name>: Storage and Handling PPHF Coordinator, workgroup member. Serves as storage and handling SME. Ensures that PPHF
storage and handling activities do not overlap with IPE project.

<name>: VFC Health Educator, workgroup member.

TBD: Instructional Designer. Will serve as evaluation design expert.

Please describe the stakeholders that have been identified and engaged. What challenges have you experienced in this process?
The awardee is in the beginning stages of planning the evaluation. There are existing relationships with VFC providers that will be
engaged to help evaluate storage and handling education materials. In addition, the State X Immunization Committee, which
includes members from State X provider organizations, will be engaged.

Please answer the questions in this table:

IPE Data Collection Instruments Current Status Challenges Experienced Changes made as a result of
(DCI) for Calendar Year 20xx the process related to or
results of this DCI
Awardee VFC Site Visit Staff
Count Survey Submitted None None
Evaluation Plan NA NA NA

Awardee Vaccine SH Knowledge,

Attitudes, Beliefs, and NA NA NA
Behaviors (A-KABB) Survey

2014 Progress Report and

Provider-level SH Outcomes NA NA NA
Assessment

2
How can CDC improve implementation and impact of IPE activities?
No suggestions offered by awardee at early point in evaluation process.

Other key points of d iscussion

Call Notes
Call duration: 20 minutes

Participants: <name> (by phone), <name>, <name>, <name>, and <name>.

No questions or concerns about this IPE SVR section or DCI #l. Many of the staff reported in DCI# 1 Table in columns 3, 4, and 5
also conduct site visits. <name> mentioned that some PPHF work might cross-over into IPE and that they would be mindful of
keeping things distinct; based on <name> 's description neither <name> nor <PO> had concerns given the structuring of IPE.
<Name> inquired about what would occur after DCI2 is submitted. <Name> described the review and sharing back of results
process and that this would be repeated for all the DCis. State X did not have any other question or concerns. <Name> mentioned
that we can have ad hoc calls, if needed, and shared that slides from DCI2 kick-off calls would be sent later the same day to
awardees who were not able to participate in those calls.

Section Ill: Vaccines for Children

{eGrATIS Units Al, A8, C2, C3, C4 Objectives)

Describe the training of VFC staff regarding policies and policy changes.
• In-person quarterly meetings
o Mandatory all-staff meetings are held quarterly in <city>. These meetings are the primary mode to conduct
education efforts on a number of topics related to VFC Field Staff as well as VFC Central Office Customer Service
Center Staff. These meetings are also held to gain insight on issues related to provider visits of all types, vaccine
ordering and accountability issues, and receive updates or education on new vaccines and vaccine schedules.
Additionally, they help maintain an ongoing link between field staff and <city> staff.
• Annual VFC Working meeting
o The goals of these meetings include allowing staff to exchange ideas and network with colleagues, allowing for
timely and important program issues to be discussed, and serving as an opportunity to develop a strategic plan to
meeting overall program requirements.
• Monthly Field Staff Calls
o Topics covered in these calls include vaccine supply and order processing updates; Quality Assurance related topics,
including site visit documentation (PEAR), administration of compliance visit and unannounced visit questionnaires;
and review of new or updates to CDC's VFC Operation Guide Modules. The calls help to ensure regular and
effective communication between field staff and management. They are used to improve collective performance,
encourage greater productivity, motivate staff to help each other succeed, discuss matters concerning vaccine
changes, and announce office changes. The monthly calls contribute to cohesiveness among co-workers and
discourage feelings of isolation that can develop with workers in the field.
• Individual region training meetings
o All five VFC Regional offices hold a monthly field staff meeting. This time is a valuable mechanism for discussing
problems, setting schedules, and reviewing rules, regulations, and policies and procedures.
• Daily Customer Service Meetings
o Central Office staff responsible for reviewing and approving orders meet on a daily basis. Meetings are used to
provide important updates on vaccine supply, vaccine order accountability and order approval guidelines, handling
provider calls, and trending topics for provider calls.

Describe the training received by VFC providers facilitated by or conducted by awardee staff.
• Compliance visits: Serve as education and training opportunities for providers and their staff on all aspects of the VFC
Program, including policies, procedures, vaccine management and accountability, and vaccine storage and handling.
• VFC Tips: Monthly communications sent through the VFC Provider listserv, focusing on a key topic and serving as
reminders to providers on meeting key program requirements.
• Focused in-person training on vaccine storage and handling and vaccine ordering and accountability is provided upon request
by clinic staff or as needed.
• Immunization Skills Institute (lSI) consists of courses organized locally by local health department (LHD) staff with

3
 assistance by Immunization Field Staff. These four-hour courses are competency-based trainings on vaccine administration,
documentation, and vaccine storage and handling. The courses are designed specifically for medical assistants.
• EZIZ Educational modules are available electronically for VFC providers on the EZIZ website. Module topics include VFC
Program participation, temperature monitoring, inventory management and vaccine storage. During 20xx, all active providers
were required to complete each of these modules.

Describe the guidance given to providers regarding VFC eligibility screening and documentation.
• Providers are instructed to screen and document eligibility for all patients birth through 18 years of age, regardless of
insurance status at every immunization visit. Documentation of screening must include the following required elements:
date of screening and the VFC eligibility criteria the patient meets. If the patient has (State X Medicaid) or is eligible for
(State X Medicaid), providers must have proof of coverage (e.g., (State X Medicaid) card). If the patient has private
insurance, the provider must have documentation of insurance (e.g., policy number or insurance card). If the patient is
American Indian/Alaska Native or has no insurance, the patient does not need to verify proof of eligibility, and the provider
is not required to have documentation of status. Documentation can be located in the liS or health record (paper or
electronic), and must be made available to the VFC Program for review upon request.

Describe how providers are selected for unannounced visits and the number planned for 20xx.
• Field representatives use a range of criteria to select providers for unannounced visits. Providers who did not meet significant
storage and handling and vaccine management requirements during compliance visits are eligible to be selected. The
Program also uses the unannounced visit format when there is an allegation of vaccine misuse, when there are unexplained
discrepancies in vaccine inventory, or just as a follow-up visit to a compliance visit during which the field staff observed the
provider had not met all VFC requirements. Field staff may also do unannounced visits to a provider in the same geographic
vicinity as another practice receiving a compliance visit. In regions where distance between providers is challenging,
targeting providers in one area is a way for field staff to maximize time in conducting visits. For 20xx, each field
representative is expected to complete at least one unannounced storage and handling visit per month, amounting to a
minimum of 132 visits for the year.

Describe plans to begin using the new CDC enrollment forms by 20xx.
• In preparation for the 2015 VFC Provider Recertification (beginning November 2014),elements included in CDC's VFC
enrollment, profile and other forms will be incorporated in the specifications for the state's online Enrollment and
Recertification systems.

Describe any apparent discrepancies between policies as written in the VFC Policy Collection Tool and policies as understood through
discussion with the awardee.
• The tool needs to be updated to reflect the current procedure for selecting providers for and conducting unannounced storage
and handling visits.

Other key points of discussion

• Regarding the role of the liS in VFC Processes:
o 317- and state-funded vaccines were previously categorized together in the liS. Due to advance credit policy
changes, the awardee has been making system enhancements since October 2013 that will allow the separation of
vaccine stock in the liS by state, 317, and VFC. The awardee hopes to have the enhancements completed by August
of this year, in time for distribution of state-purchased influenza vaccine.
o The awardee is making adequate progress in other activities according to the requirements of the cooperative
agreement.

Section IV:Immunization Information Systems

{eGrATIS Unit 0 Objectives)

The reminder/recall functionality in the liS is very flexible, but reminder/recall is not a metric that is monitored routinely. The
program states that their child participation rate (% of 0 to 5 year-olds with 2+ immunizations in State X IR) is getting considerably
smaller. The 6- to 18-year-old participation rate is also decreasing, but not as much. The hypothesis is that as providers transition to
EMRs/EHRs, State X IR is receiving less data. They hope this is a temporary situation.

State X is currently in the planning stages of replacing its legacy liS, STATE X IR 1.0, with new liS software. While the Program has
reviewed the MIROW guides, they have not implemented many of the business rules or processes due to their imminent transition.
After transition to STATE X IR 2.0, they will be able to re-examine the guidelines.
4
State X Health E-Quality, a program of the Institute for Population Health Improvement at the University of State X, is about 95%
finished with the development of a gateway/portal through which providers in State X can use to perform Meaningful Use testing and
attestation. Its functionality will support the process of setting interoperability from testing through to production. The program is
hoping for an August 1 go-live date for the immunization messaging portal. The seven STATE X IR regions will then begin using it
for their MU management. When STATE X IR 2.0 is implemented, messages will then be routed to the single/central STATE X IR
hub. The specifications for STATE X IR 2.0 include those to support interoperability with the two independent liS in State X:
<county> and <county>. While STATE X IR 2.0 funding will support the development of a link from these liS, it will not cover
support for the return of data to them; the independent liS will have to identify funds to implement this.

STATE X IR is still getting a lot of interest from the provider community, and due to the Meaningful Use incentive, staff are able to
focus more on supporting sustained participation rather than provider recruitment. Quarterly metrics run include number of providers
reporting, number of doses reported. The STATE X IR regional staff handle the provider-level management of data; they run reports
to monitor blank fields and other data quality parameters and follow- up with providers accordingly.

For each dose entered from inventory, vaccine eligibility must be confirmed. Reporting is also available to show eligibility status of
clients receiving vaccine on any given date via the "Patient Vaccine Eligibility Tracking Report."

Planning for Development and Implementation of STATE X IR 2.0:

State X is using Oregon's requirements as a starting point in the development of its own requirements for a replacement liS. Currently
the system requirements are not yet fully articulated, but a Request for Offers (RFO) has been prepared by <name>, the project
manager assigned to the project by State IT. The RFO is being reviewed by CMS. State X has applied for and been approved for a
90/10 Medicaid match to fund the replacement liS. The 10% from the state is being contributed by State Vital Records. An IAA has
been developed between DPH and DHCS (State X Medicaid).
The Program is hoping for implementation of the new system in 2015; however, they are a little behind schedule. Data migration from
STATE X IR 1.0 to STATE X IR 2.0 has been planned to take place in three phases, starting with the smaller systems in the north of
the state and finishing with <city>. The training plan has also been developed with a phased approach. <Name>, the STATE X IR
Manager in <city> has been hired by the state to be the training coordinator.

Section V: Preparedness
{eGrATIS UnitE Objectives)

Describe the aspects of pandemic influenza vaccine response/planning for which the immunization program is primarily responsible.
The Immunization Branch has limited involvement in pandemic planning currently. The Communicable Disease Emergency Response
(COER) Branch oversees pandemic preparedness planning. The Immunization Branch participates in work groups and provides
consultation as needed.

Describe the specific issues your program considers most challenging or unresolved in preparing for vaccine management during a
severe pandemic.
The awardee states that the most challenging issue in preparing for vaccine management during a pandemic is that the overall
lead responsibility for pandemic planning lies in another branch.

In a severe pandemic, in addition to using Point of Dispensing (POD) sites and other mass vaccination clinics, potentially three to four
times more providers than during HlNl may be needed in order to rapidly administer vaccinations to the public. Given this potential
for more providers and the need to process their orders, what plans do you have or actions have you taken to prepare for managing this
large volume of provider orders and their allocations?
State X's online ordering system may be easily adapted for use during a pandemic. It contains functionality for creating
download files as well as automated order approval.

Other key points of discussion: None

Section VI: American Indian/Alaska Native

(eGrATIS Unit C1 Objective)

The awardee is making adequate progress in this area according to the requirements of the cooperative agreement.

5
Section VII: Education and Partnerships
{eGrATIS Unit 81 Objectives)

The awardee is making adequate progress in this area according to the requirements of the cooperative agreement.

The EZIZ website continues to function as the main hub for VFC providers and others with an outstanding reach of
xxx,xxx unique visitors in 20xx from aliSO states as well as other countries. The website archives updates from the VFC program as
well as newsletters from the Immunization Branch and also hosts hundreds of job aids and immunization promotional materials. Of
special note are the lessons for providers housed on the website. Existing lessons include: Preparing Vaccines, Administering
Vaccines, Storing Vaccines, Monitoring Refrigerator Temperatures, Monitoring Freezer Temperatures, Conducting a Vaccine
Inventory, and VFC Education Requirements (launched in December 20xx). A training designed for LHDs on billing for
immunization services is currently in development. State X's EZIZ listserve has almost 40,000 subscribers, assisting the Program in
the timely forwarding of CDC notifications (e.g.,VIS updates and ACIP recommendations) and conducting surveys.

Section VIII: Surveillance

{eGrATIS Unit 84 Objectives)

The awardee is making adequate progress in this area according to the requirements of the cooperative agreement. Challenges
acknowledged by the awardee include difficulty in obtaining vaccine history for influenza. Staff also indicate that records are not
always updated in its statewide electronic disease reporting system, State X IREDIE, after the initial report has been submitted.

Section IX: Adolescent

(eGrATIS Unit 81 Objectives)

Describe activities to improve vaccination coverage levels and reduce disparities among adolescent s for HPV vaccine specifically.
• The awardee promoted HPV vaccination for both boys and girls at age 11-12 years as well as the importance of a strong
provider recommendation in its annual VFC provider letter announcing the new 2014 Recommended Immunization
Schedule.
• The awardee conducted focus groups with pediatricians who reported previous success in discussing the HPV vaccine with
parents. The Immunization Branch used the findings to develop an article for physicians. The finished article was sent to
AAP, ACOG, CAFP, CMA, Latino Physician Groups, Migrant Clinicians Network, and SAM. Immunization coalitions and
local health departments also distributed it to their networks.
• Staff discussed immunization against HPV during a workshop at the annual conference of the State X School Health Centers
Association.
• The awardee developed new materials for parents of preteens, including a poster that informs parents of HPV- related cancers
and a flyer. In focus groups with parents of preteens (with children who had yet not received the HPV vaccine), the flyer was
extremely well received. Nearly 80% stated that after reading the flyer they were likely to immunize their preteen boy or girl
in the next 12 months. A paired t-test also showed that there was significant knowledge gain about the HPV vaccine among
parents who read the material. The Branch also updated the popular HPV Bilingual Fotonovela for Latina moms of preteens.
• The awardee is currently updating the HPV Provider Fact Sheet to include the most current CDC data on HPV vaccine
effectiveness.
• Staff updated the Preteen Vaccine Week Kit for local health departments, local coalitions, and partners, with a special focus
on HPV vaccine, including the latest CDC data on HPV-related cancers and HPV morbidity and mortality.
• Previously, VFC staff reviewed adolescent medical charts to assess adolescent immunization coverage during VFC Quality
Assurance Visits and provided feedback to clinics. The Program plans to later incorporate the AFIX process for adolescent
immunization after the 2014 PEAR implementation process.
• The Immunization Branch is working collaboratively with the STD Branch and University of State X fellows to conduct
progress evaluation on the HPV reminder text message program. The program will start this summer. Outcome evaluation
would occur in the years to come.
• Based on feedback from a provider survey, the awardee developed HPV reminder postcards to help remind patients to come
in for their 2"d and 3rd HPV shots. The theme is "As Easy as 1, 2, 3 to Prevent HPV." The Branch plans to evaluate the
effectiveness of the cards in the coming year.
• The awardee will continue to promote all adolescent immunizations (HPV, MCV4, influenza), catch-up (especially 2nd dose
varicella), and MCV4 at age 16 years as well as Tdap (7th grade requirement).
• The awardee supported coalitions in the implementation of new personal beliefs exemption law (AB 2109) and also utilized
those speaking engagements to speak more broadly about adolescent immunizations, focusing primarily on increasing HPV
immunization rates.
6
Describe any challenges or barriers to conducting these activities effectively.
• Completion of a three-dose vaccine series in adolescent
• Lack of data on all of State X's racial ethnic groups (Most data is only for white and Hispanic populations. There is little data
on Blacks and Asian/PI and subgroups.)
• No mandated registry participation

Describe activities to improve and/or sustain vaccination coverage levels and reduce disparities among adolescents for all ACIP-
recommended vaccines in general.
• The awardee promoted meningococcal conjugate booster at age 16 years and 2nd dose varicella vaccine in annual VFC
provider letter along with the new 20xx Recommended Immunization Schedule.
• Staff will continue to hold regular meetings with state health programs regarding the latest ACIP recommendations and
potential dissemination through their respective programs (e.g. Medi-State X, Child Health and Disability Prevention
Program, Maternal Child and Adolescent Health [MCAH],Indian Health, Refugee Health, State X Department of Education,
State X Department of Social Services).
• State X Department of Public Health (XDPH) is currently developing regulations to implement a two-dose varicella
requirement at kindergarten and above (currently one-dose requirement for incoming students ages 4 through 12 years) and at
7th grade advancement (time-limited for 7 years),two-dose MMR requirement for admission to K-12 (currently just at age 4-
6 years and in grade with a 2 dose measles requirement), and 3-dose hepatitis B vaccine requirement for K-12 grades
(currently just for those admitted at age 4-6 years). Regulation package completed by Immunization Branch and is going
through internal approvals. These changes will help to improve immunization rates in school-aged youth, including
adolescents across race/ethnicities, urban/rural areas) for catch up vaccines (2 doses of MMR, 3 doses of hepatitis B, 2 doses
varicella) as well as Tdap due to requirements. The sentinel requirement for Tdap at 7th grade should help to increase rates
for MCV4 and 1st dose HPV as well.
• Implementation activities are ongoing for the recent law passed effective January 1, 20xx, which requires parents wishing a
personal beliefs exemption (PBE) to receive education from a health care practitioner regarding required immunizations and
the diseases that they prevent. Both the authorized healthcare practitioner (HCP) and the parent/guardian must sign
documentation within six months of any new child care or school immunization requirement. The official form, developed in
multiple languages, has been disseminated to LHDs for local dissemination and also is available online at shotsforschool.org.
A webinar, FAQs, and other resources regarding this new law are also posted on the website. The awardee will examine rates
of PBEs (Spring/Summer 2015) and overall immunization rates (NISin 20xx} after implementation.
• ACIP recommendations for Tdap with each pregnancy were shared with state MCAH program for further dissemination to its
corresponding local programs. Staff are working with state MCAH to possibly add questions on Tdap and influenza vaccine
administration to their survey of women with recent live birth (Maternal Infant Health Assessment survey), currently in the
pre-testing phase.
• The awardee will continue to maintain shots for school.org, a website for schools, child care providers, health professionals
and parents about immunization requirements. This website features materials for parents about other recommended
adolescent immunizations.
• Staff conducted activities to promote Preteen Vaccine Week, an observance that highlights the importance of recommended
immunizations for adolescents, in February 20xx. Staff updated the promotional kit for LHDs, coalitions, and partners with
tools to help promote all age appropriate immunizations at the community level
• Staff updated a popular flyer for parents of preteens to highlight recommended immunizations at age 11or 12.

Describe any challenges or barriers to conducting these activities effectively.

• The regulation process for updates to school and child care immunization requirements takes several years for approvals and
finalization.
• Rates of PBEs and immunization rates have multiple influencing factors, so it may be difficult to determine the specific
effects of the new law.
• No mandated registry participation.

Other key points of discussion: None

7
Section X: Perinatal Hepatitis B
(eGrAT/5 Unit CS Objectives)

*2011U.S. data are from 2009, the most recently available year.
**"Number of Expected Births" is from 2009 data,the most recently available year.

Key points of discussion regarding the perinatal hepatitis B program.

The Perinatal Hepatitis B Coordinator position is vacant. The awardee is recruiting to fill it at this time. For case management
documentation, LHDs currently submit paper forms for entry into an Access database. The program hopes to transition to
electronic documentation via State X IREDIE at some point in the future.

Section XI: AFIX

(eGrATIS Units 81, 83 Objectives)

Please describe areas of the AFIX program for which the awardee would like additional technical assistance?
Until 2014, State X's policy was to combine VFC compliance visits with AFIX activities. Given that staff members
were already in the facility reviewing charts for eligibility and administration documentation, staff also reviewed
charts for UTD status and missed opportunities. When CDC no longer accepted State X's missed opportunities protocol
for reviewing only 10 charts during an AFIX visit in 2014, staff shifted focus of the visits to VFC requirement
compliance only. The awardee used January 20xx as a period of training staff on recently launched PEAR system. In
order to meet the CDC recommendation of doing visits to 25% of providers annually,with the challenges of staff and
resources, the program anticipates that it would be difficult to achieve the goal without combining VFC-AFIX activities
as was the previous protocol. With both PEAR and AFIX documentation occurring online, the program is now exploring
ways for staff to utilize two online systems concurrently to conduct one VFC-AFIX visit. The awardee indicated that it
would prefer for AFIX questions to be included as part of the compliance visit questionnaire in PEAR to make the visit
more efficient. While the program proposed initially to conduct AFIX visits with 49% of its VFC-enrolled providers,
staff now indicate that most likely only 10% of VFC- enrolled providers will receive an AFIX visit in 2014.

Other key points of discussion.

With CDC's new requirement of re-running coverage reports within six months of the initial AFIX visit, the program will
again be conducting AFIX visits with LHDs where staff already routinely utilize the liS. Immunization data can be readily
downloaded into CoCASA to run coverage reports for the initial and subsequent follow up visit. While private providers
are enrolled in the state liS, they may not be routinely entering immunization data; consequently, their histories may
not be complete, and their liS-based coverage levels would not be representative of their true coverage.

Section XII: Adult

(eGrATIS Unit 81 Objectives)

Describe the awardee's knowledge,use, and planned implementation of the updated Adult Immunization Standards.
(http://www.hhs.gov/nvpo/reports/nvacstandards.pdf. The standards emphasize the importance of routine assessment of
8
vaccination status and provider recommendation for adult vaccines. It outlines responsibilities for healthcare providers, public
health departments and medical specialty organizations to ensure effective evidence-based efforts to increase adult
immunization rates).
The awardee already addresses each of the Adult Immunization Standards informally through ongoing activities. For example,
to determine community needs and barriers to adult immunization, the program plans to continue to add questions to
population-based surveys, such as BRFSS and CHIS. The awardee also partners with stakeholder and promotes awareness
in its pneumococcal vaccine awareness campaign. For this campaign, staff contacted community stakeholders
representing vaccinating provider organizations, pharmacists, and organizations representing high-risk adults.
Organizations agreed to include a message in their fall newsletter to coincide with National Adult Immunization Week.
To ensure professional competencies in immunization, EZIZ lessons are readily available online for all providers. Data
from BRFSS is analyzed and summarized annually. To provide outreach and education, a pneumococcal vaccine
awareness flyer was developed and distributed to over 100,000 State X senior citizens at Area Agencies on Aging
throughout the state in December 20xx. In an effort to decrease disparities, the program collaborates with the State X
Immunization Coalition to reach Latino seniors in Southern State X for targeted influenza messaging. The state has also
done extensive work in the area of developing capacity for billing for immunizations,specifically in <County>. This
model is now being used to develop statewide online billables training for LHD staff, to be launched during this calendar
year.

Describe plans to increase awareness of adult vaccination among adults and increase provider assessment and
recommendations of vaccines for adults.
The awardee has promoted vaccines recommended for adults in a variety of ways including:
• Email communications to providers via provider listserv on EZIZ
• Email communications to provider associations (AAP, AAFP, CMA, etc.)
• Support of National Adult Immunization Awareness Week (NAIAW), including email communications and social media
messaging
• Article in IZ Update (newsletter for providers and immunization stakeholders)
• Various partnership activities with State X Department of Aging, Area Agencies on Aging (AAA),and State X
• Immunization Coalition
• Direct mailing of adult immunization materials to AAA

Describe existing activities for administering vaccines to adults by public health or supplying other providers with
vaccines for adults.
State General Funds allowed for the purchase of approximately 600,000 doses of influenza vaccine and 60,000 doses
of Tdap vaccine during 20xx and 20xx. Both vaccines are distributed to LHDs. With regards to flu vaccine, local
health departments are encouraged to hold outreach clinics in locations where adults have less access to health care.
In terms of Tdap vaccine, doses were distributed based on requests that target pregnant women, postpartum
women, and household contacts of infants.

Describe plans or activities to decrease racial and ethnic disparities in vaccination among adults.
The Immunization Branch encourages LHDs to hold flu clinics in locations and at times that would be more convenient
for adults with less access to health care. A committee was formed to assess disparities among different age groups,
including adults. The work is ongoing and will eventually produce a document that will guide future efforts.

Other key points of discussion.

The awardee has not yet formally incorporated the new Adult Immunization Standards into its strategic planning
process nor shared the new standards with adult immunization providers.

Section XIII: PHHF

State X is the recipient of IP12-1206PPHF12 funding for Program Area 5 {Storage and Handling). All activities are on
track for this cooperative agreement. The awardee plans to apply for a no-cost extension.

9
2014 Site Visit Summary and Recommendations

Area(s) of Strength (Project Officer observation):

State X's Immunization Branch has created an impressive resource for providers and the general public with its EZ-IZ website. The website hosts multiple
immunization trainings for providers and serves as a repository for hundreds of immunization job aids and educational materials. EZ-IZ has a tremendous reach and is
routinely accessed by users both in all 50 states and outside the United States. The Program does an incredible job in ensuring that the website remains current and
user-friendly through the routine evaluation of its offerings.

The awardee continuously seeks to maximize efficiency through automation of processes whenever possible. Online VFC enrollment and ordering processes have
previously been automated online. Now the Program has implemented an online provider suspension tracking system, which will help in identifying and
standardizing reasons for provider suspensions, data that has not been collected previously. A follow-up notification system for field representatives has been
developed,and plans are in place for an automated system that would notify providers of vaccine order status.

Operational or Programmatic Challenges (challenges outside the direct control of the Program):

The Immunization Branch has been without a permanent Branch Chief since February 20xx. The field-assigned PHA, <name>, served in that capacity until February
20xx when <name> assumed the role of Acting Branch Chief.

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 20xx Recommendations:

Topic Area Sub-Topic 20xx Recommendation Project Officer Comments

Vaccines for Site Visit- When conducting VFC compliance visits, Recommendation based on observation of VFC
Children (VFC) Compliance reviewers must observe the VIS dates on the compliance visit.
actual VIS forms being distributed to
patients/parents. Observing "current VIS dates"
in a list is not sufficient.
Vaccines for Site Visit- When conducting VFC compliance visits, Recommendation based on observation of VFC
Children (VFC) Compliance reviewers must view the certificate of calibration compliance visit.
for the temperature monitoring device in use by
the provider. Asking the provider if there is a
certificate and the date on it is not sufficient.
AFIX Program Planning Plan field representative training and provider The current recommendation is for 25% of VFC-enrolled
visit activities to maximize AFIX activities to be providers to receive an AFIX visit annually. The HP
completed during 20xx. 2020 Objective 17 goal is for 50% of both public and
private providers to receive AFIX visits annually.
Adult Immunization Program Share new Adult Immunization Standards with
Management- adult immunization providers.
Education
Adult Immunization Program Planning Incorporate new Adult Immunization Standards
into Program's strategic planning efforts.
General Other, specify Capitalize on opportunities to increase public As outbreaks occur or articles or studies are published
awareness of immunization topics with the use regarding vaccines or vaccine- preventable diseases,
of press releases, social media ,etc. share information as appropriate with providers as well as
the general public.

___________________________________________ ______________________

Project Officer, Program Operations Branch Date

___________________________________________ ______________________

Chief, Program Operations Branch Date

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2014 VFC Site Visit Observational Tool (for use by Project Officer)

Awardee:

Date of Visit:
Type of VFC Visit:
Person Conducting Visit:

Item Yes No N/A or Notes

1. Was the CDC pre-visit guide used in preparation for X
CA has added some items to
the visit? (pre-visit guide, as written, is required). PVG.

2. Was Questionnaire sent prior to the visit? X

3. Is Reviewer entering data directly into PEAR online
while onsite? (NOTE: If “no,” please describe process X
for entering data into PEAR).
4. Reviewer asked questions in a non-leading manner? X
5. Reviewer asked all questions on the questionnaire? X
6. Storage & Handling issues identified and corrected? X
7. Reviewer verified the following documentation:
Vaccine borrowing reports N/A – doesn’t allow borrowing
Vaccine management plan X
Vaccine Information Statements X *See comment below
Temperature logs for last 3 months X
Current/Valid Certificate of Calibration Asked if she had them &
provider said yes, exp. date
X
2015. Did not physically view
cert.
8. Reviewer verified the following storage & handling
practices:
Proper placement of thermometer in refrigerator X
Proper placement of thermometer in freezer X
Use of Do Not Disconnect sign X
9. Does the Reviewer full review the data and action X
taken related to any temperature excursions?
10. Is the Reviewer knowledgeable about the X
temperature monitoring units used by the provider?
11. Follow-up was correctly addressed during the visit? X

Notes/Comments:
*Reviewer checked VIS dates by reading list posted on the folder where the VISs were kept. Reviewer
should verify dates on the actual VISs.

-Great emphasis on coverage rates. Provider had COCASA reports run ahead of visit and voluntarily
discussed their reminder/recall efforts and pre-emptive efforts to avoid missed opportunities.
 20xx AWARDEE RESPONSE TO RECOMMENDATIONS

The Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Immunization Services Division is charged with the fiduciary
responsibility of monitoring and tracking the progress of all awardee applications for funds.

In accordance with this legal requirement, the Immunization Program of State X is hereby requested to submit a Response to Recommendations addressing each of the
recommendations being made by the Project Officer conducting this site visit.

The Response to Recommendations should be submitted electronically to the Project Officer within thirty (30) days after receipt of this report. Please use the following format:

STATE X Immunization Program

Response to Recommendations CDC/ISD/POB Technical Assistance Site Visit
Conducted March xx-xx, 20xx

Topic Sub-Topic Recommendation Awardee Action(s) to be Responsible Person(s) Completion

Taken Date/Comments

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