ACP’s Center for Quality has received funding from the CDC, GSK and Merck to support our I Raise the Rates initiative. The program aims to increase adult and influenza vaccination coverage among older adults, adults with high-risk chronic conditions, and racial/ethnic minority adults by using quality improvement (QI) methodology. Please complete this application if you are interested in participating. Applicants will be considered on a first come, first served basis.

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* 1. Full Name

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* 2. Credentials

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* 3. Email Address

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* 4. Pharmacy/Organization Name

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* 5. Pharmacy Address

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* 6. Number of pharmacists

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* 7. Number of pharmacy support staff

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* 8. How many pharmacists from your practice do you anticipate will participate in this program?

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* 9. Please describe your pharmacy setting/type (e.g., community-chain pharmacy, community-independent pharmacy, clinic-based pharmacy, grocery-store based pharmacy, hospital pharmacy, other.)

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* 10. Do you have support from your organization’s leadership to participate in ACP’s I Raise the Rates QI program?

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* 11. Do you have at least one pharmacist team member that can serve as project lead on behalf of your practice for this program?

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* 12. Do you currently administer flu and other adult vaccines in your practice?

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* 13. Which immunizations would you like to focus you QI project on?

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* 14. Is your practice located in a rural, urban, or other medically underserved community?

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* 15. Is your practice able to provide the following data to ACP pre-/post-initiative?

  Yes No
Immunization rates (de-identified, aggregated at the practice level)
Practice assessment survey (completed by one practice lead on behalf of practice)
Mini-z survey (completed by each participating clinician)

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* 16. How many years have you been in practice?

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* 17. Which of the following best describes your race/ethnicity?

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* 18. Is there a local primary care practice that you would like to collaborate with on this program?

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* 19. Please provide contact information of the local primary care practice you would like to collaborate with on this program (optional).

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