Pledge & Order Form Please complete this order form for materials to promote HPV Vaccination at your clinic/organization in the month of August. All materials will be provided at no cost to you. We only ask that you please send photos of your materials on display. Question Title * 1. Number of "Ask Me About the HPV Vaccine" Buttons for Staff you would like: 5 10 15 20 25 Question Title * 2. Number of "HPV Vaccination is Cancer Prevention" Lanyards for Staff you would like: 5 10 15 20 25 Question Title * 3. Number of laminated 8.5x11" Routine School Age Vaccine Checklists you would like: 5 10 15 20 25 Question Title * 4. Number of laminated 8.5x11" Vaccine Schedule Posters you would like: 5 10 15 20 25 Question Title * 5. Number of laminated 4.25x5.5" Provider FAQ Cue Cards you would like: 5 10 15 20 25 Question Title * 6. Number of 3.5x2" Patient Vaccine Follow-up Appointment Cards you would like: 50 100 150 200 250 Question Title * 7. Number of 4x6" Patient Vaccine Reminder Postcards you would like: 50 100 150 200 250 Question Title * 8. Please enter your mailing information below: Name of package recipient Name of organization Mailing Address Mailing Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number Take the Pledge! Commitment of signing the Campaign Partner Pledge• Plan & Implement at least one activity to increase HPV Vaccination rates in your practice or community for Alaska HPV Vaccination Month (August 2023)• Develop a follow-up plan to complete the HPV vaccination series for those you reached• Share your story with us to help inspire Partners next year Question Title * 9. Select one or more activities your organization will implement for Alaska HPV Vaccination Month (August 2023) CME Training for staff - we can provide you with a CME-approved presentation developed by the CDC or the Alaska Cancer Partnership Start recommending vaccination at age 9 in our clinic Include HPV vaccination in your standing orders Send reminders to patients who are due or need to finish the series - we can send you co-branded postcards Provide patient and parent education materials in your waiting room - see www.hpvcancerfreeak.org/resources for printable materials Add extended hours to your clinic for vaccination or organize a special HPV vaccination event Join the Alaska Vaccine Assessment Program to provide no cost immunizations - learn more at www.akvaccine.org Develop a provider reminder system for your health records Provide an incentive for patients who get the vaccine or finish the series Measure your current vaccination rates and set a goal to improve them - we can help you do this Promote HPV Vaccination on our social media and/or website Other (please specify) Question Title * 10. Do you have any questions or need support to implement any of these activities? If yes, someone from the HPVCancerFreeAK Team will contact you within 7 business days. Yes No Question Title * 11. Please upload your logo for our Campaign Partners webpage PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please upload your logo for our Campaign Partners webpage Done
