Cloud Online Nomination Form

The Arizona Partnership for Immunization (TAPI) is seeking nominations for the 2020 Toddler and Teen Cloud Awards. These awards recognize the exceptional efforts of the many practices who have improved immunization coverage levels statewide for toddlers and teens. 

Upon nomination completion, the practice/clinic will be contacted and will run their own ASIIS data-driven report to validate coverage levels. Instructions will be provided and technical assistance will be available via STC, as needed.

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* 1. Cloud nomination type (Choose only one - If you would like to submit for both awards, please complete a separate nomination for each category):

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* 2. Provide VFC PIN Number (If not applicable, put N/A):

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* 3. Provide the full name of nominated practice/clinic:

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* 4. Provide the full address for the nominated practice/clinic:

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* 5. Provide the full name for the contact person onsite at the nominated practice/clinic:

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* 6. Provide the email address for the contact person onsite at the nominated practice/clinic:

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* 7. Provide the direct phone number for the contact person onsite at the nominated practice/clinic:

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* 8. Provide the extension number for the contact person onsite at the nominated practice/clinic:

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* 9. Provide your full name (This is for the person submitting the nomination form):

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* 10. Provide your email (This is for the person submitting the nomination form):

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