Action Kit Evaluation Form - Immunisation printable pdf download

ACTION kit evaluation form

2013

Immunisation

The Pharmaceutical Society of Australia would appreciate your feedback by answering the following questions:

Personal details

Self Care subscription number (if known):

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Pharmacy name:

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Contact name:

Address:

Suburb/Town:

State:

Post Code:

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Phone:

Mobile:

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Email:

1. Did you conduct an in-store health promotion or host

Pre-immunisation screening checklist

a service?

Customer vaccination statement template

In-store promotion

Emergency response protocol

Service

Referral letter template

Both

Fact Cards

Posters

2. Which of the education resources did you use?

Appointment card

Clinical evidence brief

Health column

Facts Behind the Fact Card article

Customer feedback form

Counter Connection article

Staff feedback form

PSA Movitational interviewing

PSA Collaboration online

5. Did the tools meet your needs?

PSA Immunisation – an overview online

Yes

PSA Implementing an in-pharmacy influenza immunisation

No – If no why not:

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service online

6. How could these kits be improved?

PSA Immunisation services in pharmacy – guidelines

Australian Immunisation handbook

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Group 3 template

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Staff training presentation

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Community group presentation

Thank you for taking the time to complete this evaluation.

If yes, who did you use it with?

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We value your feedback in guiding the development of future

ACTION kits.

3. Did this education meet your needs?

Please fax your response to 02 6285 2869 or mail to:

Yes

PSA Self Care

No – If no why not:

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