Forms and Tools
All the forms and tools you need as an IPI Advisor.
IPI Program Forms
- MnVFC Pre-Visit Worksheet (PDF: 117KB/1 page)
- Word Autofill: 32KB/1 page
- MnVFC Site Visit Questionnaire (PDF: 179KB/8 pages)
- Word Autofill: 56KB/8 pages
- Vaccine Storage Unit Checklist (PDF: 177KB/7 pages)
Form for completing the storage unit portion of the visit questionnaire. It includes spots for four different storage units. Make additional copies as necessary. Updated 3/15
- Word Autofill: 56KB/7 pages
- Guidance for the Site Visit Questionnaire and Vaccine Storage Unit Checklist (PDF: 242KB/10 pages)
Use to educate and provide resources to providers who need to take action in an area identified on the site visit questionnaire and the vaccine storage unit checklist. Updated 4/15
- MnVFC Visit Summary (PDF: 145KB/3 pages)
Summary of items needing improvement and/or follow-up from the MnVFC site visit. Updated 3/15
- Word Autofill: 39KB/3 pages
- MnVFC Visit Cover Sheet (PDF: 120KB/1 page)
This form is completed with EACH and EVERY type of visit, i.e. MnVFC Site Visit, Educational, or Follow-up. This form has the basic demographic information on the clinic and the IPI person doing the visit. It is also the checklist for which forms need to be sent to MDH. Updated 3/15
- Word Autofill: 31KB/1 page
- Educational Visit Form (PDF: 113KB/1 page)
Formal presentation to clinic staff where an agenda, PowerPoints, and handouts are produced. Complete the Visit Cover sheet along with this form and include any materials and a list of attendees. Updated 3/15
- Word Autofill: 30KB/1 page
- Follow-Up Form (PDF: 110KB/1 page)
Complete this form as you do follow-up to address issues found on a MnVFC site visit. Updated 3/15
- Word Autofill: 30KB/1 page
- Minnesota Department of Health Vaccine Programs (PDF: 57KB/1 page)
This flyer provides an overview of the three different vaccine programs offered through MDH.
- HIPAA and Access to Patient Records during AFIX and VFC Visits
Responses to frequently asked questions about HIPAA and access to patient records during AFIX and site VFC visits. Attention: Non-MDH link
- Acceptable Coolers for Vaccine Transfer or Transport (59KB/1 page)
Which coolers should you use? Use this chart to help you choose includes cooler type, description and examples, when and how to use, and monitoring temperatures off-site.
- Clinician's Vaccine
Mishap Checklist (PDF: 29KB/1 page)
A checklist for clinical staff that find themselves with a vaccine storage and handling mishap. Updated 5/14
- Vaccine Storage Guide
Two-page illustrated guide to vaccine storage temperatures and where and how to store vaccine in a refrigerator-only unit, freezer-only unit, and combination refrigerator/freezer unit. Includes tips for proper storage and management of vaccines.
Immunization Assessment Forms/Tools:
- Immunization Assessment Questionnaire (PDF: 82KB/2 pages)
Questions for IPI advisors to ask during an immunization assessment visit. Updated 3/15
- Data Collection Confidentiality Agreement For Records Abstractor (PDF:44KB/1 page)
Agreement form to be completed by the IPI Advisor before beginning a review of clinic immunization information.
- Nine Practical Ways to Improve Clinic Immunization Rates (PDF:34KB/2 pages)
A list of nine strategies for increasing immunization rates.
Below are sample letters IPI Advisors may use when communicating with clinics. Please only use as a guide. Updated 4/14