HPV QI Program – QIDA Enrollment Name * First Last Name * Last Credentials * Email Address * Main Phone Backline Phone Core Team Role Physician Lead Nursing Lead Administrative Lead Practice/Organization * Practice Street Address * City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Do you have a National AAP Member ID No.? No, please provide me with information on how to acquire this number Yes, AAP Member ID is:Yes, AAP Member ID is: Are you seeking Quality Improvement board-specific accreditation? No Yes - My accrediting board is:Yes - My accrediting board is: How did you find out about this opportunity? (Ohio AAP Today, postcard, direct email, etc.) Do you know yet who your other Core Team members will be? Yes No Names and roles: Do you enter immunizations into ImpactSIIS? Yes No Are you a VFC provider? Yes No If you are human, leave this field blank.
