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* 1. Facility Name

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* 2. Facility CCN (aka Medicare Provider number- 6 digits starting with either 08 or 39)

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* 3. Facility email contact

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* 4. What activities (videos, handouts, games, puzzles, etc.) do you plan to implement to promote patient vaccinations?

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* 5. What activities do you plan to implement to promote staff vaccinations?

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