Welcome to My Survey
Thank you for completing the Tracking Immunization Delayed Children Monthly Outreach Report (Revised 08/2018). This report is used to monitor activities related to tracking immunization delayed children, including collaboration and outreach with WIC and local providers, as per the Local Health Department Conditions of Award. Priority should be placed on tracking immunization delayed children between the ages of zero and four (0-4) years. Please feel free to contact the Center for Immunization at 410-767-6679 if you need assistance or have questions.
COUNTY INFORMATION

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* 1. Reporting Month:

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* 2. Reporting Year:

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* 3. County/Jurisdiction:

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* 4. Contact Information:

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* 5. Please provide today's date:

Date
CASELOAD SUMMARY  -  please complete all blank fields.

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* 6. Provide the number of NEW cases from each referral source for this month:

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* 7. Provide the number of NEW cases by age group for this month:

**CHECK YOUR DATA: The sum of question 6 should equal the sum of question 7.

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* 8. How many cases were carried over (from previous months)?

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* 9. Provide the TOTAL number of cases tracked for this month
(new cases + cases carried over from previous months):

**CHECK YOUR DATA: Question 9 should equal the SUM of question 6 + question 8 OR the sum of question 7 + question 8.

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* 10. Provide the number of cases found to be up-to-date (FUTD) from each referral source for this month:

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* 11. Provide the number cases found to be up-to-date (FUTD) by age group for this month:

**CHECK YOUR DATA: The sum of question 10 should equal the sum of question 11.

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* 12. Provide the number of cases brought up-to-date (BUTD) from each referral source for this month:

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* 13. Provide the number cases brought up to date (BUTD) by age group for this month:

**CHECK YOUR DATA: The sum of question 12 should equal the sum of question 13.

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* 14. Provide the number of cases lost to follow-up (LTF) among WIC referrals for this month:

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* 15. Provide the number of cases lost to follow-up (LTF) among other (non-WIC) referrals for this month:

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* 16. Provide the TOTAL number of cases forwarded to the next month by referral type   (total # of cases tracked for the month - # FUTD - # BUTD - total # LTF):

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* 17. Please list/describe your outreach activities for this month:

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* 18. Do you have any additional comments? Feel free to include challenges and/or successes:

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