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.
Full Name
*
First Name
Last Name
Credentials
Business or Organization Name
*
Email Address
*
Physician Tracking
# of physicians on staff
# of physicians who received the Tdap vaccine
# of physicians excused for medical reasons or those with up-to-date shots
Healthcare Personnel
# 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
Office Staff
# 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.
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