EPIC Immunization Request Form  Survey

1.Select which program (s) your office would prefer below:(Required.)

Childhood Program (Birth - 18yrs.) - 1.5 hrs.

Childhood Program - short version - 1.0 hr.

Adolescent Program (9 - 18yrs.) - 1.25 hrs.

Adult Program (19yrs. - Senior) - 1.5 hrs.

Combo Program (Birth - Senior) - 1.75 hrs.

Coding Program for Childhood Immunizations - 1.25 hrs.

Women's Health Program (OB/GYN practices) - 1.5 hrs.

Healthcare Professionals in Training (Schools) - 1.5 hrs

Improving HPV Rates in Your Practice - 1.0 hr.

Vaccine Hesitancy - 1.0 hr

COVID-19 Program - 1.0hr. NEW!

2.Who is requesting this program?(Required.)

Name & Title:

Email Address: (required)

Practice/Organization:

Practice Address:

Contact Number:

3.Which presentation option is best for your practice?(Required.)

Option A - Live Webinar Presentation - A zoom meeting will be set up on the date and time selected by your practice.

Option B - Pre-scheduled Webinar Presentation - Dates for each EPIC curriculum will be pre-scheduled and sent to your practice to register. Start time is usually 12:30 pm. (Maximum of 10 practices can sign up for each webinar)

Option C - Pre-recorded Webinar Presentation - Your practice can request access to an archived webinar to view individually at your own convenience or during office hours at various times.

Option D - In person at your practice

4.What dates/times work best for your practice?

5.How did you find out about our programs?