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2nd Dose Program Survey 1
1.
What are your 2nd Dose Immunization Rates for:
Enter the % for at least one of the measures below (a, b, c and/or d).
a.
2nd Dose COVID-19 %
Percentage
Data as of: (enter date MM/DD/YYYY)
b.
2nd Dose Meningococcal ACWY % (e.g. Menactra%)
Percentage
Data as of: (enter date MM/DD/YYYY)
c.
2nd Dose Meningococcal B % (e.g. Trumenba/Bexsero %)
Percentage
Data as of: (enter date MM/DD/YYYY)
d.
2nd Dose HPV (e.g. Gardasil /Gardasil 9%)
Percentage
Data as of: (enter date MM/DD/YYYY)
e.
2nd Dose Adult Hepatitis B % (Heplisav-B only)
Percentage
Data as of: (enter date MM/DD/YYYY)
*
2.
Were your rates higher, lower or exactly what you expected?
(Required.)
Higher than Expected
Lower than Expected
Exactly as Expected
*
3.
Do you plan on implementing change in your practice in the next 12 months to improve these rates?
(Required.)
Yes
No
If yes, describe the strategy you plan to implement…
To process the CPP educational grant of $500, please provide the following information:
*
Practice Name
(Required.)
*
Practice Address
(Required.)
*
Contact Name
(Required.)
*
Contact Email Address
(Required.)
*Please note: CPP will only use your contact information to issue the educational grant check. CPP will not collect any patient specific information. All immunization rates will be analyzed and reported as general trend data and will not be attributed to an individual practice.
