Immunize WA 2023 Nomination Form

Thank you for your interest in the Immunize WA Award. Please make sure to submit this form and send in your coverage rate reports. Directions can be found here. You can only submit one form per clinic, you may need to delete your internet cookies to submit other clinics. You may submit multiple clinics under one email, please remember to include VFC pin numbers in subject line.

Nomination form closes July 6, 2023, late submissions will not be accepted.

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* 1. Did you submit your coverage rate report to immunizewa@doh.wa.gov? Directions to generate your reports can be found here.

Yes

No

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* 2. Please list the first and last name of the best contact person for any questions regarding the nomination.

First name

Last name

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* 3. What is the best email address for the contact entered above?

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* 4. What is the name of the clinic to be printed on the certificate? P

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* 5. What health care organization is your clinic affiliated with? For example Kaiser-Permanente, Multicare, Providence, Tribal Clinic, or Independent Practice.

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* 6. Please provide the mailing address. This is the address that certificate will be mailed to.

Street Address

City

State

Zip Code

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* 7. What is the VFC pin number for the clinic?