Arizona Partners Against Pertussis 2012 - 2013 Campaign Tracking Form
By completing this form, I certify that our organization achieved 100% pertussis immunization rate for eligible physicians, healthcare personnel, and staff.
Business or Organization Name
# of physicians on staff
# of physicians who received the Tdap vaccine
# of physicians excused for medical reasons or those with up-to-date shots
# of healthcare personnel on staff
# of healthcare personnel who received the Tdap vaccine
# of healthcare personnel excused for medical reasons or those with up-to-date shots
# of personnel on staff
# of personnel who received the Tdap vaccine
# of personnel excused for medical reasons or those with up-to-date shots
Thank you for participating in this important patient safety initiative. Return this form by April 1st and your organization will be entered in a random drawing to receive an iPad or one of five $100 gift cards.
Should be Empty: