NIPA HPV Learning Collaborative Enrollment (cohort 4)
Take a Shot!

National Immunization Partnership with the APA (NIPA)
Improving HPV Immunization Coverage

We are pleased that your practice will be participating in this nationwide quality improvement project to improve adolescent human papillomavirus (HPV) immunization rates.
Submission of this enrollment form is consider consent to participate in this learning collaborative.

Individuals who participate in the project are eligible to earn:
- 25 credits toward Maintenance of Certification (MOC), Part 4 from the American Board of Pediatrics (ABP)
- MC-FP credit for 1 Part IV module or 20 Part IV points, from the American Board of Family Medicine (ABFM)
- Up to 20 Performance Improvement Continuing Medical Education (CME) credits

In order to earn project credit, individuals must:
- Attend the Project Orientation webinar
- Participate in 5 of 6 monthly Learning Collaborative webinars
- Complete project surveys (Office Systems Inventory- pre/post, Staff Impact Survey- post, PDSA Log- monthly for 6 mos)
- Submit patient data (HPV rates- pre/post, missed opportunities- monthly for 9 mos)

Question Title

* 1. I have read the above project requirements.

Yes

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* 2. Practice Contact Information

Practice Name:

Address:

City/Town:

State:

ZIP:

Phone Number:

Fax Number:

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* 3. Preferred Method(s) of Contact:

Phone

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* 4. Please select the category below that best characterizes your practice.

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* 5. Are you a FQHC?

Yes