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Application - I Raise the Rates: Initiative to Increase Adult and Influenza Vaccine Coverage

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Full Name:

Credentials:

Email Address:

Practice Name:

Practice Address:

City/Town

State/Province

ZIP/Postal Code

Country

Number of physicians in your practice:

Number of non-physicians in your practice:

How many clinicians do you anticipate will participate in this program?

Please describe your practice type/setting (e.g. academic medical center, residency program, community health center, hospital-based practice, independent primary care practice, multi-specialty practice, etc.)

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

Yes

Do you have at least one physician and one non-physician team member that can serve as project leads on behalf of your practice for this program?

Yes

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

Yes

Which immunizations would you like to focus your QI project on?

Flu

Pneumococcal

Tdap

Shingles

COVID-19

RSV

All adult vaccines

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

Yes

Unsure

Is your practice able to provide the following ACP pre/post-initiative?

Immunization rates (de-identified, aggregated at the practice level)

Yes

Practice assessment survey (completed by on practice lead on behalf of practice)

Yes

Are you currently an ACP member?

Yes

ACP ID Number:

How many years have you been in practice?

0-5 years

6-11 years

11-15 years

16-20 years

21+ years

Prefer not to answer

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 answer

A race/ethnicity not listed (please specify)

Other:

What is your specialty?

General Internal Medicine

Subspecialty (please specify)

Other (please specify)

Specialty:

Other: