PROVEN Strategies to Increase the Quantity and Quality of Adolescent Well Visits in YOUR Practice Webinar Evaluation Choose webinar date: * June 8, 2017 June 15, 2017 Name * First and Last Name (This is the name that will appear on your CME Certificate) Credentials Email Address * Name of Practice * Practice - Street Address * Practice - City * Practice - State * Ohio 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 Practice - County * Number of Physicians at Your Practice * 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 20-24 24-29 30+ Percentage (%) of Population that is on Medicaid: * Average # of Patients Seen Per Week (Unduplicated): * Specialty * Primary Care Medical Subspecialty Surgeon Hospitalist Urgent Care OtherOther How can the Ohio AAP Assist in meeting your education needs? * Email Address At the conclusion of this activity, are you able to: Explain specific strategies around increasing adolescent well-visits, both scheduling and attendance * Yes No Utilize Bright Futures recommendations as context for the well visit * Yes No Effective communication strategies with parents: Including risk/benefit analysis * Yes No Improve adolescent attendance at comprehensive well-visits through outreach via social media, electronic communications, tools and incentives for office staff, and using episodic care, acute care, and sports clearance to increase comprehensive well visits * Yes No Improve the quality of care delivered at visit * Yes No Differentiate between fear and lack of knowledge of adolescent health topics * Yes No Describe best practices in use of reminder/recall tools in practice and adolescent immunizations Tdap, Meningococcal (ACWY and B), Influenza, and HPV * Yes No Change the paradigm of how adolescents and families view their health care between the ages of 11-18 years * Yes No Would you like to receive resources for your practice? Yes, via email Yes, via US mail No, thank you Please enter your address (Practice name, street address, city, state, ZIP) Would your practice be interested in joining a Quality Improvement program focused on increasing the quantity and quality of adolescent well visits? * Yes No If yes, which program format would be most appealing? Online, self-directed In-person learning session and monthly group webinars Practice facilitation – a practice coach works one-on-one with your practice: they will travel to you, enter your data and transform your practice based on your individual needs Additional Comments/Questions: If you are human, leave this field blank.