2016 Immunize Washington Nomination Form

Immunize Washington 2016 Nomination Form

Thank you for participating in the Immunize Washington Recognition Program!

First, please run your Coverage Rate Reports from the Washington State Immunization Information System (IIS) using the instructions provided. Coverage Rate Reports should be sent to Immunizewa@doh.wa.gov

Once your Coverage Rate Report has been sent, please fill in the form below to confirm your nomination.

For more information, including the instructions for running the Coverage Rate Report, please visit www.doh.wa.gov/immunizewa

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* 1. What is the name of your clinic? (Please use the name listed in the IIS, if available)

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* 2. What is your Vaccines for Children (VFC) PIN? (if unknown or unavailable, you may skip this answer)

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* 3. Please list the best contact person your clinic.

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* 4. Please provide the following contact information for the clinic.

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number: *

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* 5. Type of clinic?

Pediatric

Family Medicine

Community Health Center

Other (please specify)

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* 6. How did you hear about the Immunize Washington Recognition Program?

DOH Communication

Local Health

Health Plan Newsletter

Flyer or Material Left After In-Person Visit

Other (please specify)

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* 7. Please list the total number of patients included in your coverage rate report in the field next to the appropriate age and series below. You can find your total number of patients under the “Total Patients” column of the coverage rate report.

You only need to complete this survey once to submit your nomination for both the childhood and adolescent immunization series. You just need to run two separate coverage rate reports for these age groups and series.

Childhood (24-35 months) 4313314

Adolescent (13-17 years) 332211

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* 8. Please list the percentage of patients who are up to date for the selected series in the field next to the appropriate age and series below. You can find your percent up to date under the “Series Complete” column of the coverage rate report.

You only need to complete this survey once to submit your nomination for both the childhood and adolescent immunization series. You just need to run two separate coverage rate reports for these age groups and series.

Once finished, please save and send Coverage Rate Reports to Immunizewa@doh.wa.gov

Childhood (24-35 months) 4313314

Adolescent (13-17 years) 332211