For IPI Advisors

Immunization

All the forms and tools you need as an IPI Advisor.

Forms on this page:
Forms
Tools
Immunization Assessment Forms/Tools
Sample Letters

IPI Program Forms

Provider Questionnaire (PDF:70KB/7 pages)
An assessment tool to be used with clinics prior to the site visit. [Updated 2/13]
Word Autofill: 289KB/7 pages
- Rationale and Talking Points for Provider Questionnaire (PDF:167KB/6 pages)
  The companion to the IPI Program Provider Questionnaire. [Updated 2/13]
Clinic Checklist (PDF:88KB/7 pages)
An assessment tool to be used during the site visit. [Updated 2/13]
Word Autofill: 322KB/7 pages
- Multiple Vaccine Storage Unit Checklist (PDF:83KB/3 pages)
  Word Autofill: 157KB/3 pages
- Rationale and Talking Points for Clinic Checklist (PDF:156KB/8 pages)
  The companion to the IPI Program Clinic Checklist. [Updated 2/13]
Visit Cover Sheet (PDF:26KB/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 2/13]
Word Autofill: 56KB/1 page

Educational Visit Form (PDF:29KB/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 2/13]
Word Autofill: 49KB/1 page

Follow-Up Form (PDF:24KB/1 page)
Complete this form as you do follow-up to address issues found on a MnVFC site visit. [Updated 2/13]
Word Autofill: 149KB/1 page

Tools

Site Visit Checklist (PDF: 32KB/1 page)
Use this list to help prepare for a clinic visit. [Updated 3/13]

IPI Advisor Training Checklist (PDF: 33KB/1 page)
Immunization program, IPI site visits, storage and handling, and clinical practice checklists for IPI advisors. [Updated 3/13]

IPI Advisor Resource List (PDF: 95KB/2 pages)
List of helpful resources for IPI advisors. [Updated 3/13]

Minnesota Department of Health Vaccine Programs (PDF:93KB/1 page)
This flyer provides an overview of the three different vaccine programs offered through MDH. [Updated 10/12]

HIPAA and Public Health Site Visits: Access to Patient Records during AFIX and VFC Visits (PDF:727KB/81 pages)
Please note: The HIPAA and Public Health Site Visits section starts on page 40 of the PDF. Responses to frequently asked questions about HIPAA and access to patient records during AFIX and site VFC visits. Attention: Non-MDH link

Immunization Data Sharing and HIPAA
A summary of the Minnesota law allowing for sharing of immunization data.

IPI Protocol for Vaccine Storage and Handling Mishaps (PDF: 44KB/2 pages)
A guide for working with clinics that encounter a vaccine storage and handling mishap. [Updated 3/13]

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. [Updated 3/11]

Clinician's Vaccine Mishap Checklist (PDF: 41KB/2 pages)
A checklist for clinical staff that find themselves with a vaccine storage and handling mishap. [Updated 3/10]
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:

MDH Immunization Assessment Provider Summary (PDF:107KB/2 pages)
Template to assist IPI advisor and clinic personnel with an immunization assessment. This template can be given to the clinic and sent to MDH after the visit as a part of the materials for MNVFC/immunization assessment visits.
Word Autofill:85KB/2 pages [Updated 3/11]