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 * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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: Are you seeking Quality Improvement board-specific accreditation? No 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
