EPIC Immunization Trainer Interest Form Survey

1.Please complete your contact information below:(Required.)

Name:

Position:

Phone Number:

Email (required):

2.What is the name of your Practice/Facility?(Required.)

Name:

Address: (include city and zip)

Phone Number:

3.Which program (s) would you be interested in presenting?(Required.)

Childhood Program (Birth - 18yrs.) - 1.5 hrs.

Adolescent Program (9 - 18yrs.) - 1.25 hrs.

Adult Program (19yrs. - Senior) - 1.5 hrs.

Combo Program (Birth - Senior) - 1.75 hrs.

Coding Program for Childhood Immunizations - 1.25 hrs.

Women's Health Program (OB/GYN practices) - 1.5 hrs.

Healthcare Professionals in Training (Schools) - 1.5 hrs

Improving HPV Rates in Your Practice - 1.0 hr.

Vaccine Hesitancy - 1.0hr.

4.Which of these descriptions represent your current status?(Required.)

Physician - Current member, in good standing, of your professional association or academy including Georgia Chapter American Academy of Pediatrics (GAAAP). Currently practicing in a setting that actively immunizes clients or hold a position that requires knowledge of current immunization practices, requirements and regulations (CDC/NIP, Georgia Immunization Program, EPIC Advisory Committee member, etc).

Nurse Practitioner or Physician Assistant - Current member, in good standing, of your professional association or academy. Currently practicing in a setting that actively immunizes clients or hold a position that requires knowledge of current immunization practices, requirements and regulations (CDC/NIP, Georgia Immunization Program, EPIC Advisory Committee member, etc).

Immunization Nurse or Coordinator - Currently working as an immunization nurse or coordinator of a practice or facility engaged in active immunization of clients and employs practices for enhancing immunization knowledge through education and immunization initiatives. Knowledge of immunization coding and reimbursement practices. Minimum of two (2) years required. Licensed as a Registered Nurse preferred.

Practice Manager - Currently working as a manager of a practice or facility engaged in active immunization of clients and employs practices for enhancing immunization knowledge through education and immunization initiatives. Knowledge of immunization coding and reimbursement practices. Minimum of two (2) years experience required.

Other (please specify)