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Get University of Washington Form IV: Health Center Questionnaire

Ame of interviewer: Date: HEALTH FACILITY GENERAL INFORMATION Cold chain function: Which of the following cold chain functions does the health facility provide? Mode of routine vaccine supply: How are routine vaccines supplied to this health facility? Mark only ONE box Mark ALL boxes that apply Delivered Collected Both Storage Outreach immunization services Static immunization services None Health facility energy sources available to power cold chain equipment Grid electricity: What is .

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