FACILITY INFORMATION- This includes Provider name, vaccine delivery address, address.

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1 COMPLETING THE PROVIDER PROFILE FORM 1. VFC Provider Profile Form This form is computer-fillable for your convenience. If you prefer to handwrite, please write clearly and legibly. The following sections need to be completed: FACILITY INFORMATION- This includes Provider name, vaccine delivery address, address. VACCINE DELIVERY INSTRUCTIONS Include delivery hours. Providers update hours with each order but please provide general hours of operation. FACILITY TYPE Check the appropriate box. Public = county or state health department run by state employees Private = not county or state health department. Not run by state employees. FQHC/RHC = Federally Qualified Health Center/Rural Health Center. This is a state designation. If you cannot confirm state designation, you are not FQHC/RHC. Check the appropriate box. Provider Specialty- self explanatory VACCINES OFFERED- self explanatory PROVIDER POPULATION- To complete the Provider Population Table you will need the following reports from GRITS: Doses Administered by Eligibility Report Vaccine Usage Report Alternatively, your in-house EMR may be able to provide this information. If not see page 2 for a helpful guide to calculating the population estimates using your GRITS reports. Incomplete Population estimates will not be accepted! TYPE OF DATA USED TO DETERMINE PROVIDER POPULATION self-explanatory, choose all that apply. VACCINE STORAGE UNITS- Must be completed or your site will be at risk for suspension. Indicate your refrigerator type and freezer type if applicable. Please note that Household freezers cannot be used for vaccine storage Provide calibration dates for primary and secondary/back-up thermometers. Thermometers need to be re-calibrated based on expiration date. Try to stagger dates so that both the primary and secondary thermometers are not out for re-calibration at the same time. Note that as of 2018, all providers must purchase Data Logger Thermometers 1

2 HOW TO COMPLETE THE PROVIDER POPULATION TABLE To complete the Provider Population Table you will need the following reports from GRITS: Doses Administered by Eligibility Report Vaccine Usage Report Instructions on how to run the reports in GRITS How to run the Doses Administered by Eligibility Report Log in to GRITS with your regular login and password 1. From the main menu on the left click on request dose admin under Reports request dose admin is under Reports 2

3 2. Choose your selection from the Site(s) menu You can create reports for all sites combined or all sites listed separately depending on your needs. 3

4 3. Click the calendar icon to enter the date range for the previous year, from January 1, 2015 to December 31, Click the Generate Report button. Click the Refresh button until the status is 100% If you have multiple sites, request all sites listed separately. The system will generate a multiple page report broken down by site. If you only have one site, the system will generate a single one page report. 4

5 Status is 50% here after just 1 or 2 clicks of the refresh button. Status is 100% here 5

6 How to run the Vaccine Usage Report Log in to GRITS with your regular login and password 1. From the main menu on the left click on request dose admin under the VFC menu request vaccine usage is under Reports 6

7 2. Choose your selection from the Site(s) menu and input your date range using the calendar icon. 3. Click Generate Report 4. Click the Refresh button until the status is 100% (usually within 1 or 2 clicks) Once you have obtained your reports, you are ready to proceed with the calculations. 7

8 Start by using the DOSES ADMINISTERED BY ELIGIBILITY Report. It provides data by category and can be used to get the big picture i.e. totals. Run the report for the 12 month Vaccination Period: 01/01/ /31/2015. SAMPLE DOSES ADMINISTERED BY ELIGIBILITY REPORT* (*some data has been omitted for clarity) Vaccination Period: 01-JAN-15 to 12-DEC-15 (Provider Population based on patients seen during the previous 12 months required for recertification) Grou p Name New/ Historica l Insured Vaccine s Covered Medicai d Peac h Care American Indian/Alask a Native No Insuranc e Insured- No Vaccine s IGNORE THESE VALUES Not Determined/Unknow n TOTAL S Totals: DO NOT USE THIS VALUE 169 Medicaid, American Indian/Alaska Natives and No Insurance are VFC Eligible categories. All other categories are Non-VFC. Do not use the totals in the Not Determined/Unknown column. Use these totals to fill in the totals in the Provider Population Table in the Provider Profile Form Use the totals from the Doses Administered by Eligibility Report to fill in the totals of the Provider Population Table in the Provider Profile Form. See example below: 8

9 PROVIDER POPULATION Provider Population based on patients seen during the previous 12 months (estimates are required for new clinics). Report the number of children who received vaccinations at your facility, by age group. Only count a child once based on the status at the last immunization visit, regardless of the number of visits made. The following table documents how many children received VFC vaccine, by category, and how many received non-vfc vaccine. VFC Vaccine Eligibility Categories # of children who received VFC Vaccine by Age Category <1 Year 1-2 Years 3-6 Years 7-18 Years Total Enrolled in Medicaid 106 No Health Insurance 18 *American Indian/Alaska Native **Underinsured in FQHC/RHC or Deputized Facility Total VFC: Non-VFC Vaccine Eligibility Categories # of children who received non-vfc Vaccine by Age Category <1 Year 1-2 Years 3-6 Years 7-18 Years Total Insured (private pay/health insurance covers vaccines) 22 Other Underinsured 2 Children s Health Insurance Program (CHIP) 3 (Amerigroup, Peach State, WellCare) 12 Total Non-VFC: 34 Total Patients (must equal sum of Total VFC + Total Non-VFC) These totals came from the Doses Administered by Eligibility Report (see sample report on the previous page) 9

10 Once the totals are in, the next step is to breakdown the data by age. For that, use the VACCINE USAGE Report for the same time period. Start by filling in the zeros: *Since the population of American Indian/Alaska Native is negligible in the state of Georgia, you can fill in zeros for each age group in that category. **Since the majority of providers are not deputized to be FQHC, then most of you will be able to fill those categories with zeros as well. The Vaccine Usage Report will help fill out the VFC eligibility categories by age. SAMPLE VACCINE USAGE REPORT* Vaccination Period: 01-JAN-15 to 01-JAN-16 (Provider Population based on patients seen during the previous 12 months required for recertification) (*some data has been omitted for clarity) Grou p Nam e Trad e Nam e Fundin g < PUBLI C PUBLI C PUBLI C PUBLI C Totals: Total s Waste d Expire d Error s Client Counts **Use Client Counts to calculate estimates. **Use Client Counts to calculate estimates. This will ensure that each child is only counted once per CDC guidelines Report the number of children who received vaccinations at your facility, by age group. Only count a child once based on the status at the last immunization visit, regardless of the number of visits made 10

11 For the Enrollment Estimates portion of the recertification process, you will need the following age categories as per CDC guidelines: <1, 1-2, 3-6 and 7-18 Simply add together the columns that satisfy the guidelines. Example from table above: <1 is given = 2 For 1-2, add together the columns for age 1 and age 2 from the Vaccine Usage Report, in this case = 7. Therefore 7 will go into the column for ages 1-2 on the Provider Profile form required for recertification. For 3-6, add together the columns for age 3-5 and age 6 from the Vaccine Usage Report, in this case = 17. Therefore 17 will go into the column for ages 3-6 on the Provider Profile form required for recertification. For 7-18, add together the columns for ages 7-10 and ages and ages from the Vaccine Usage Report, in this case = 38. Therefore 38 will go into the column for ages 7-18 on the Provider Profile form required for recertification. Create a ratio: <1 = = = = 38 Therefore the ratio is 2 : 7 : 17 : 38 = 64 From these ratios, calculate the percentage by age group. So: For <1: 2/64 x 100 = 3% For 1-2: 7/64 x 100 = 10% For 3-6: 17/64 x 100 = 27% For 7-18: 38/64 x 100 = 60% Or you can say For <1: 2/64 x 100 = 3% approximately 5% of your population is <1For 1-2: 7/64 x 100 = 10% approximately 10% of your population is between 1-2 For 3-6: 17/64 x 100 = 27% approximately 25% of your population is between 3-6 For 7-18: 38/64 x 100 = 60% approximately 60% of your population is between

12 Once you have the percentages, you can guestimate the breakdown of the totals plugged in from Doses Administered By Eligibility Report. Remember- you will no longer be able to fill in the categories with fractions, decimals, percentages or leave blank. EXAMPLE (Numbers will vary depending on your site. This is just an example. Actual totals will vary when you do the real recertification). 12

13 PROVIDER POPULATION Provider Population based on patients seen during the previous 12 months (estimates are required for new clinics). Report the number of children who received vaccinations at your facility, by age group. Only count a child once based on the status at the last immunization visit, regardless of the number of visits made. The following table documents how many children received VFC vaccine, by category, and how many received non-vfc vaccine. VFC Vaccine Eligibility Categories # of children who received VFC Vaccine by Age Category <1 Year (5% of total) 1-2 Years (10% of total) 3-6 Years (25% of total) 7-18 Years (60% of total) Total Enrolled in Medicaid 5% x 106 = % x 106 = % x 106 = % x 106 = No Health Insurance 5% x 18 = % x 18 = % x 18 = % x 18 = American Indian/Alaska Native Underinsured in FQHC/RHC or Deputized Facility Total VFC: Non-VFC Vaccine Eligibility Categories # of children who received non-vfc Vaccine by Age Category <1 Year 1-2 Years 3-6 Years 7-18 Years Total Insured (private pay/health insurance covers vaccines) 5% X 22 = % X 22 = % X 22 = % X 22 = Other Underinsured 2 Children s Health Insurance Program (CHIP) 3 (Amerigroup, Peach State, WellCare) 5% X 12 = % X 12 = % X 12 = % X 12 = Total Non-VFC: Total Patients (must equal sum of Total VFC + Total Non-VFC) Do the same for all other categories making sure to use the correct percentages and totals for each age category until you have completely filled the table. If a category does not apply to your site, fill in with zeros. 13

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