New Program Evaluation Cycle - Topic Identification Report
MS Word Template

A. Program Component(s) - Specify the component you will be evaluating. 
___Adolescent vaccination			___ Perinatal hepatitis B        
___Adult vaccination				___ Population Assessment
___ AFIX (Provider Quality Assurance)	___Surveillance
___ Education/training			___Vaccine management and accountability (VFC)
___IIS 						___Women Infants and Children Program (WIC)
___Other (please specify): ____________________________________________

B. Activity and Objective - The Immunization Program Operations Manual (IPOM) previously listed activities for each component; however, the current IPOM lists objectives for each component. For your new evaluation cycle, please choose to evaluate one (or more) of the activities your program conducts to meet an objective listed in the current IPOM. Please BRIEFLY list and describe the activity and the related objective. 

C. Rationale - Please provide the rationale for why your program is choosing to evaluate this activity.

New Cycle Evaluation Lead:
Name: 
Title: 
Phone #: 
Email:
 
This form completed by:
Name: 
Title: 
Phone #: 
Email:

This document can be found on the CDC web site at: http://www.cdc.gov/vaccines/programs/progeval/downloads/new-cycle-topic-report.rtf