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<br />EXHIBIT A <br /> <br />IMMUNIZATION ASSESSMENT CRITERIA AND REPORTING REQUIREMENTS <br /> <br />Assessment Criteria: <br />Methodology used for an automated assessment must be approved by RECEIVING AGENCY as meeting <br />contractual requirements. <br /> <br />The assessment criteria below is to be used for conducting/reporting all immunization assessments. <br /> <br />CASA CliniclProvider Site Requirements <br /> <br />CASA Client Information <br /> <br />Date of Assessment <br />Common Review Date <br />Provider Type <br />Name of Clinic/Provider Site <br />Address <br />City, State, Zip Code, County Code <br />Reviewer Initials (XPR ifelectronicfile) <br />Estimated "Active" Client Population and Sample Size for <br />12-35 months of age <br /> <br />FULL Last and First Name <br />Date of Birth <br />Moved or Gone Elsewhere <br />VFC Status/Documentation <br />Shot Type <br />Shot Date <br /> <br />Reportin'l Requirements: <br />TexWin CASA clinic data files should be submitted to the Regional AFIX Coordinator and to the Texas <br />Department of Health Immunization Division-Central Office within two weeks of completion of the <br />assessment. Please contact the Immunization Division if you need the latest version of TexWin CASA or <br />assistance with data file transfer. Please include the following information with your electronic files for each <br />clinic assessment: <br /> <br />Name of assessment site and address (including County and TDH Region) <br />Mailing address (if different from above) <br />Site contact name, title, phone andfax number <br />Type ofsite(s) (e.g., LHD, TDH. WIC, etc.) <br />Date of assessment <br />Description offiles (e.g., cardfiles, medical records. ICES, TexWin, other electronic) <br />Exclusive criteria (must be approved by RECEIVING AGENCY) <br />Name, address, and phone number of individual that performed the assessment <br /> <br />Detailed explanation Q.f reminder/recall criteria: <br />