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

ACP’s Center for Quality has received funding from the CDC to support our I Raise the Rates initiative. The program aims to increase adult and influenza vaccination coverage among patients with high-risk chronic conditions and racial/ethnic minority adults by using quality improvement (QI) methodology. Please complete this application if you are interested in participating. Applicants will be considered on a first come, first served basis.
1.Full Name(Required.)
2.Credentials(Required.)
3.Email Address(Required.)
4.Practice Name(Required.)
5.Practice Address(Required.)
6.Number of physicians in your practice(Required.)
7.Number of non-physician clinical staff in your practice(Required.)
8.How many clinicians do you anticipate will participate in this program?(Required.)
9.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.)(Required.)
10.Do you have support from your organization’s leadership to participate in ACP’s I Raise the Rates QI program?(Required.)
11.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?(Required.)
12.Do you currently administer flu and other adult vaccines in your practice?(Required.)
13.Which immunizations would you like to focus your QI project on? 
14.Is your practice located in a rural, urban, or other medically underserved community?(Required.)
15.Is your practice able to provide the following data to ACP pre-/post-initiative?(Required.)
Yes
No
Immunization rates (de-identified, aggregated at the practice level)
Practice assessment survey (completed by one practice lead on behalf of practice)
Mini-z survey (completed by each participating clinician)
16.Are you currently an ACP member ?
17.How many years have you been in practice?
18.Which of the following best describes your race/ethnicity?
19.What is your specialty?