Flu Event Summary - TotalWellness

Flu Coordinator Event Summary

Please complete this form and submit.

Event Date*
MM slash DD slash YYYY
Event Number (ex: 12345)*
Client*
Event Location*
Lead Staff Name*
Who was your TotalWellness Account Manager?*
How many flu shots were administered?*
Please enter a number from 0 to 9999.
How many flu shot participants had appointments?*
How many flu shot participants were walk-ins?*
How many flu shot participants were no-shows?*
How many Covid Shots were administered?*
Enter 0 if Covid shots were not offered at your event.
Please enter a number from 0 to 9999.
How many Covid participants had appointments?*
How many Covid participants were walk-ins?*
How many Covid participants were no-shows?*
How many 65+ flu shots were administered?*
Enter 0 if 65+ flu shots were not offered at your event.
Please enter a number from 0 to 9999.
How many 65+ participants had appointments?*
How many 65+ participants were walk-ins?*
How many 65+ participants were no-shows?*
Please ask the eHS screening lead for participation numbers and enter the data below.
Were you able to obtain the screening participation numbers from the eHS team lead?*
How many screenings were administered?*
Please enter a number from 0 to 9999.
How many screening participants had appointments?*
How many screening participants were walk-ins?*
How many screening participants were no-shows?*
Did the event start on time?*
Please provide start time and explanation:*
Did the event end on time?*
Please provide end time and explanation:*
Overall Participant Feedback*
Site Contact Name and Feedback:*
Issues that affected the outcome of the event (IE. Missing supplies, staff issues, etc.)
Overall success:*
Did you utilize iPads to complete Flu Consent Forms?*
- Yes
- No, the event was set up to use paper forms
- No, I switched to paper forms
Did you collect any paper consent forms not entered into the iPad?*
- Yes
- No
Did you complete a time extension form?*
Please return paperwork (time logs, temp logs, etc.) via FedEx with your vaccine return.
If you completed flu consents onsite using an iPad, please upload the documents listed below.
Time Log*
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.
Time Extension Form*
Max. file size: 50 MB.