2025 Alaska HPV Vaccination Month Pledge and Order Form Survey

Commitment of signing the Campaign Partner Pledge

• Plan & Implement at least one activity listed below to increase HPV Vaccination rates in your practice or community for Alaska HPV Vaccination Month (August 2025)

• Share your story with us to help inspire Partners next year

1.Please enter your information below:(Required.)

Your Name and Title

Name of Organization

Mailing Address

Mailing Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number

In the following questions 3-5, please select one or more activities that your organization will implement for Alaska HPV Vaccination Month (August 2025). We've organized them as POLICY Activities, PROVIDER Activities, and PATIENT Activities - choose as many as you like. We can send you resources to help you along the way!

2.POLICY Activities

Create a clinic policy to start recommending HPV vaccination at age 9

Create a clinic policy for providers to recommend HPV vaccination at each visit

Create a clinic policy to include HPV vaccination in your standing orders

Create a clinic policy to schedule the next HPV vaccination visit before the patient leaves the clinic

Learn how to enroll your clinic in the Vaccines for Children (VFC) Program or the Alaska Vaccine Assessment Program (AVAP) to provide no cost immunizations. We'll put you in touch!

For VFC participating clinics, learn how to enroll in the Immunization Quality Improvement Program (IQIP). We'll put you in touch!

Other (please specify)

3.PROVIDER Activities

Develop a provider reminder system for your health records

Measure your current vaccination rates and set a goal to improve them. We can help you do this!

Host a CME Training for staff on giving a strong recommendation. We can provide you with CME-approved presentations!

Other (please specify)

4.PATIENT Activities

Send reminders to patients who are due or need to finish the series. We can send you fillable postcards!

Add extended hours to your clinic for vaccination or organize a special HPV vaccination event

Provide an incentive for patients who get the vaccine or finish the series

Promote HPV Vaccination on your social media and/or website

Provide patient and parent education materials in your waiting room - see www.hpvcancerfreeak.org/resources for printable materials

Other (please specify)

5.How many individual clinics/sites will be impacted by your pledge activities? (please list)

6.Would you like to order no cost HPV Vaccination Month Campaign Materials (stethoscope clips, handouts, posters, etc.)?(Required.)

Yes, please! - You will be directed to the Order Form

No, thank you. - You are finished. We will follow-up with you soon to see how we can support your efforts!

2025 Alaska HPV Vaccination Month Pledge and Order Form

Take the Pledge!