2016 MnVFC Educational Visit*
*Visit needs prior approval from your MnVFC clinical coordinator/planner.
Visit date:
Visit time:
Site Information
Site name:
MnVFC PIN:
Vaccine Coordinator or Immunization Manager:
IPI Advisor Information (staff that performed visit)
IPI Advisor:
Phone:
County:
Email:
Education
Purpose of the visit:
Information discussed at visit:
Did you attach a copy of your PowerPoint presentation? ☐ Yes ☐ No ☐ N/A
List any handouts or brochures given out at the visit. (No copies are necessary)
Attach a roster with participant names
Notes:
To be completed by MnVFC clinical coordinator/planner at MDH
Date reviewed:
Signature:
IM M UNI ZA T IO N P RA CT I C E S IM PR OV EM E NT (I P I)
February 2016