Job Corps Health

Sections

IMMUNIZATION SURVEY (2008) (open)

If you have any questions, please contact Julie Luht at 301-608-3290 X 407 or email at Julie.Luht@humanitas.com

1) Center Name (Required)

2) Name of Person Completing Survey (Required)

3) Phone # (Required)

Email (Required for confirmation) (Required)

4) Is your center currently a Vaccine for Children (VFC) provider? (Required)

Yes
No

4a) If no, has your center been a VFC provider in the past?

Yes
No

4b) If you are not currently a VFC provider, provide a reason

5) Vaccine cost information. Check all that apply

MMR	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Td Tdap	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
IPV	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Hepatitis A	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Hepatitis B (HBV)	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Varicella	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Tuberculin skin test (TST)	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Influenza	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Gardasil (HPV4)	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?
Menactra (MCV4)	Free through VFC for students 18 and under Free through state or local agency (select all that apply) At cost What is the cost per dose? Supplier: Other If Other is selected, please specify Not offered Why is this vaccine not offered?

Center ID Number (Required)

The Center ID number is also used to complete the Annual Program Description Report (Ex. AB123)

Comments and questions are welcome . . . Please e-mail the Job Corps Health Webmaster

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