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Field Operations

Field Operations Provider Feedback Questionnaire

* Indicates required field

*Provider:
*Provider PIN:
*Provider Type: Private Provider: Public Provider:
*Provider Contact:
*Provider's Telephone:
*Field Staff Name:
(For multiple selections, use the Control key [Windows] or the Command key [Macintosh] when you click to select or de-select.)
Position Title:
*County
*Date of Visit:
 
The following evaluation form will be used to better understand how well the Immunization Program field staff members work with their assigned VFC Program providers. The results of this feedback questionnaire are kept confidential and will be used as part of an overall measurement for field staff members' annual performance evaluations and to identify opportunities for improvement. Please score your field staff representative from 5 (highest) to 1 (lowest).
 
QUESTION SCORE COMMENTS
Please score the performance of the Field Staff representative based on the following criteria: 5 = Strongly Agree
to
1 = Strongly Disagree 		Please add any comments that you feel will be beneficial for the evaluation process.
5 4 3 2 1
Field Staff representative arrived on time.
Field Staff representative was professional and appropriately dressed.
Field Staff representative was prepared and organized.
Field Staff representative discussed Florida SHOTS™ and provided training as necessary.
Field Staff representative was knowledgeable of Advisory Committee on Immunization Practices (ACIP) recommendations and immunization practices.
Field Staff representative discussed vaccine storage and handling.
Field Staff representative is accessible to me by telephone, e-mail, and in person when I need advice or assistance.
I have confidence in the professional advice and recommendations I receive from my Field Staff representative.
I am pleased with the service provided by my Field Staff representative.
Additional Comments
*To confirm this is a valid application, please enter the number in the box below:

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  • Florida Department of Health
  • Vaccine Adverse Event Reporting System - Opens in new window
  • Centers for Disease Control and Prevention - Opens in new window
Bureau of Immunization Vaccination Education Series - Opens in new window
This page was last modified on: 08/30/2012 04:21:06