Pharmacists Application - I Raise the Rates Initiative to Increase Adult and Influenza Vaccination Coverage

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.

Question Title

* 1. Full Name

Question Title

* 2. Credentials

Question Title

* 3. Email Address

Question Title

* 4. Pharmacy/Organization Name

Question Title

* 5. Pharmacy Address

Question Title

* 6. Number of pharmacists

Question Title

* 7. Number of pharmacy support staff

Question Title

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

Question Title

* 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.)

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Flu

Pneumococcal

Tdap

Shingles

COVID-19

All adult vaccines

Question Title

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

Yes

Not Sure

Question Title

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

Question Title

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

0-5 years

6-10 years

11-15 years

16-20 years

21+ years

Prefer not to say

Question Title

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

White or Caucasian

Asian or Asian American

Hispanic or Latino

Black or African American

Native Hawaiian or other Pacific Islander

Prefer not to anser

A race/ethnicity not listed (please specify)

Question Title

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

Yes

Question Title

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

Name

Company

City/Town

State/Province

Email Address