Date* Company Name* First Name* Last Name* Email Address* Street Address City* Telephone* Person conducting the visit* Did the visit * Exceeded my expectations Met my expectations Did not meet my expectations Please explain why.* Upon completion of the site visit do you feel you had a better understanding of general immunization information, the VFC Program, and immunization recommendations and requirements?* Yes No If no please explain. What was the most valued component of the visit?* What was the least helpful component of the visit?* What could be added to improve the visit?* Was there adequate notification given prior to the visit?* Adequate time was given The visit was planned to far in advance Not enough notice was given Did the person conducting allow adequate time to discuss issues, concerns and provide the necessary training? * Not enough time was allowed The visit took too long to complete for the information provided An adequate amout of time was given to complete the visit Was the site visit relevant to the office need?* Yes No If no please explain Was the information discussed and presented during the site visit in a manner you and your staff could understand?* Yes No If no, what could have been done to improve the delivery of the information? Following the visit did you receive the follow-up training or information that was needed?* Are you comfortable contacting your local health department regarding immunizations and immunization training?* Yes No How does the site visit information reach your practitioners and what is the timeframe for them to review the information?* Additional comments: