Colorado School District Immunization Fact Sheet Expression of Interest Form

Please complete this brief form to confirm your interest in your local school district fact sheet(s) and to help us to prioritize fact sheet creation efforts.

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* 1. Please complete the contact information below.

Name

Title

Email Address

Phone Number

LPHA/Organization

Address

Address Line 2

City

State

Zip Code

Organization Website

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* 2. Please list the school district(s) for which you would like to partner with CCIC to create a fact sheet(s).

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* 3. What county/counties does your organization serve?

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* 4. Please select the option that best describes the nature of your current relationship with your local school district(s) partners.

Our LPHA works closely with our local school district(s) and has a strong relationship and regular communication with school nurses and administration.

Our LPHA has relationships established with our local school district(s), but it could be improved.

Our LPHA does not currently have a strong established relationship with our local school district(s).

Comments

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* 5. Please describe how you plan to use and disseminate the fact sheet(s) (i.e. how you plan to engage and partner with school nurses and school district administration in your area to best utilize and deliver this resource)

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* 6. Please provide 2 sentences to tailor the Case in Point (or Successes) section for your district(s) on the back, bottom left corner. This can include VPD case information similar to what we have for Boulder or general information highlighting what efforts have worked well in your community/district to get to high immunization and/or compliance rates. (i.e. X district has achieved high vaccination rates through partnerships between our local health department and school nurses and by conducting x, y, and/or z.)
If requesting more than one district, this information can be the same for multiple districts if applicable, or can include highlights for some and point out an outbreak or room for improvement on others) You may also reach out to elizabeth.abbott@childrenscolorado.org to discuss further.

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* 7. If you have an estimate of the number of fact sheets you would need us to provide to you, please include that here. (If you have capacity to print in color and only require a PDF, please note that here also)

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* 8. Do you have any feedback, comments, suggestions and/or questions related to the example Boulder Valley School District draft shared with you?

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* 9. Please list any other relevant information, comments or questions you may have here.

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* 10. Are you a CCIC Member? First priority will be given to members of CCIC. You can learn more about the benefits of membership and to sign up to be a CCIC member on our website here

Yes

I'm not sure

Thank you for completing this form. Upon submission, a CCIC staff member will follow-up with you within two weeks.

If you have any immediate questions, please feel free to contact Liz Abbott at elizabeth.abbott@childrenscolorado.org.

Thank you!