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Question Title

Sign-On Commitment

We, the undersigned organization, commit to prioritize adolescent HPV vaccination to prevent cancer. By signing on to this initiative, we agree to the following:

1) We will determine our baseline HPV vaccination rates for adolescents by age 13.

2) We will work collectively as part of this national movement to raise rates towards 80% for boys and girls.

3) We will immunize to prevent HPV cancers and protect adolescent population health.

4) We will set a performance improvement goal to deliver on-time HPV vaccination for all our adolescent patients (i.e., 2 shots by age 13).

We understand that we will have the option to share information about our work, if we so choose.

We will have the option of sharing our high level baseline rates.

We will have the option of sharing mid-year and end of year progress updates via short online forms.

We may be asked to share our progress on future webinars, social media channels, blogs or e-newsletters.

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* Organization Contact Information

Whom is the person completing this form?

Title

Organization Website

Key Contact Email

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* Organization Type

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* Organization Address

Street/P.O. Box

City/Town

State

ZIP/Postal Code

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* States Included in Your Organization's Service Area

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* Additional Key Contact #2 for HPV Vaccination Work

Name

Title

Phone

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* Additional Key Contact #3 for HPV Vaccination Work

Name

Title

Phone

NOTE: All contacts provided on this form will be considered as opting in to receive We’re In! 2020 e-newsletters.

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* HPV Baseline Information

This is optional information that your organization may provide now or by March 2020.

Estimated # of adolescent patients served per year

Current HPV vaccination rate by age 13 (if known)

Estimated performance improvement target

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* Organization Contact Information

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* Organization Type

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* Organization Address

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* States Included in Your Organization's Service Area

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* Additional Key Contact #2 for HPV Vaccination Work

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* Additional Key Contact #3 for HPV Vaccination Work

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* HPV Baseline InformationThis is optional information that your organization may provide now or by March 2020.

* HPV Baseline Information

This is optional information that your organization may provide now or by March 2020.