HPV Immunization Rate Improvement Project Application (HPV-IRIP)

In an effort to prevent cancer, the New Hampshire Comprehensive Cancer Collaboration (NH CCC) has dedicated funding to support providers who are interested in improving adolescent immunization rates, specifically HPV. Funds can be used to support staff time to plan, implement and evaluate HPV improvement projects.

The following survey is an application for a $2,500 stipend to clinics interested in improving their HPV vaccination rates through implementing evidence-based strategies including use of standing order, reminder/recall systems, provider prompts and use of strong provider recommendations.

Question Title

* 1. Contact Information:

Name

Phone

Organization

Role in Organization

Question Title

* 2. The following questions relate to the current strategies you are using to improve HPV vaccination rates:

	Yes	No	Unsure
Provider prompts for HPV vaccination (e.g., a flag in the chart, etc.)?	Provider prompts for HPV vaccination (e.g., a flag in the chart, etc.)? Yes	Provider prompts for HPV vaccination (e.g., a flag in the chart, etc.)? No	Provider prompts for HPV vaccination (e.g., a flag in the chart, etc.)? Unsure
Standing order for HPV vaccination for all children 11 to 13 years-old?	Standing order for HPV vaccination for all children 11 to 13 years-old? Yes	Standing order for HPV vaccination for all children 11 to 13 years-old? No	Standing order for HPV vaccination for all children 11 to 13 years-old? Unsure
HPV reminder project (e.g., post-cards, phone calls, etc.)	HPV reminder project (e.g., post-cards, phone calls, etc.) Yes	HPV reminder project (e.g., post-cards, phone calls, etc.) No	HPV reminder project (e.g., post-cards, phone calls, etc.) Unsure
HPV recall project (e.g., calls when people are due for next series)	HPV recall project (e.g., calls when people are due for next series) Yes	HPV recall project (e.g., calls when people are due for next series) No	HPV recall project (e.g., calls when people are due for next series) Unsure

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* 3. The following questions relate to your plans to improve HPV vaccination rates within your clinic:

	Yes	No	Unsure
Develop a system for provider prompts related to HPV vaccination.	Develop a system for provider prompts related to HPV vaccination. Yes	Develop a system for provider prompts related to HPV vaccination. No	Develop a system for provider prompts related to HPV vaccination. Unsure
Develop a reminder system for families when a child is due for vaccination.	Develop a reminder system for families when a child is due for vaccination. Yes	Develop a reminder system for families when a child is due for vaccination. No	Develop a reminder system for families when a child is due for vaccination. Unsure
Develop a recall system for families when a child is due for follow-up HPV vaccination.	Develop a recall system for families when a child is due for follow-up HPV vaccination. Yes	Develop a recall system for families when a child is due for follow-up HPV vaccination. No	Develop a recall system for families when a child is due for follow-up HPV vaccination. Unsure
Develop a system to ensure standing orders for any child between 11-13 for HPV vaccination.	Develop a system to ensure standing orders for any child between 11-13 for HPV vaccination. Yes	Develop a system to ensure standing orders for any child between 11-13 for HPV vaccination. No	Develop a system to ensure standing orders for any child between 11-13 for HPV vaccination. Unsure

Question Title

* 4. The following questions relate to your current capacity to look at HPV immunization rates in your clinic:

	No	Yes, for the entire clinic	Yes, for the entire clinic and by provider	Unsure
Are you able to determine the percentage of females and males 13 years of age who have initiated the HPV vaccine series?	Are you able to determine the percentage of females and males 13 years of age who have initiated the HPV vaccine series? No	Are you able to determine the percentage of females and males 13 years of age who have initiated the HPV vaccine series? Yes, for the entire clinic	Are you able to determine the percentage of females and males 13 years of age who have initiated the HPV vaccine series? Yes, for the entire clinic and by provider	Are you able to determine the percentage of females and males 13 years of age who have initiated the HPV vaccine series? Unsure
Are you able to determine the percentage of females and males 13 years of age who have *completed* the HPV vaccine series?	Are you able to determine the percentage of females and males 13 years of age who have *completed* the HPV vaccine series? No	Are you able to determine the percentage of females and males 13 years of age who have *completed* the HPV vaccine series? Yes, for the entire clinic	Are you able to determine the percentage of females and males 13 years of age who have *completed* the HPV vaccine series? Yes, for the entire clinic and by provider	Are you able to determine the percentage of females and males 13 years of age who have *completed* the HPV vaccine series? Unsure