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		Calendar of Events
		Request an IEP
		Order Materials
		Become a Presenter
		American Academy of Pediatrics (AAP) immunization web site See the American Academy of Pediatrics (AAP) web site for latest AAP immunization recommendations and policy statements.

PA Immunization
Education Program
c/o PA Chapter, AAP
Rose Tree Corporate
Center II, Suite 3007
1400 N Providence Rd
Media, PA 19063

PA Only: 800-375-5214
Phone: 484-446-3004
Fax: 484-446-3255

E-mail: iep@paaap.org

By filling out and submitting this form, your request for information will be e-mailed to the Pennsylvania Immunization Education Program. Please note that fields in red are required. Depending on your selection in Section 2, you will also be required to fill out the appropriate corresponding section below. Thank you.

SECTION 1

Personal Information

Name:

Degree:

MD
DO
CRNP

PA
RN
Other:

Practice Name:

Practice Type:

Pediatrics
Family Practice
Mixed
Other:

Address 1:

Address 2:

City:

State:

Zip:

E-mail:

A copy will be e-mailed to the address provided

Phone:

Must be in 123-456-7890 format.

Fax:

Must be in 123-456-7890 format.

SECTION 2

I would like to:

Your Request:

Schedule an On-Site IEP Presentation (Go to Section 3)
Become a Presenter (Go to Section 4)
Order Materials (Go to Section 5)
Request Other Information (Go to Section 6)

SECTION 3

Schedule an On-Site IEP Presentation

VFC Provider?:

Yes
No
If yes, VFC Pin #

We would like to schedule an Immunization Education Program for our staff. Here are three potential dates for the 1 1/2 hour presentation.

Date	Time of Day
//
//
//
Use format: MM/DD/YYYY	Example: 9:30 AM

SECTION 4

Become a Presenter

NOTE:

You will be asked to provide a current CV and to sign an annual disclosure form to meet CME guidelines.

Provider Type:

Pediatrician
Family Physician
Nurse Practitioner

Physician’s Assistant
Nurse
Office Manager

Access to Slide Projector:

Yes
No

Access to LCD Panel:

Yes
No

Access to a Laptop Computer:

Yes
No

I am willing to travel to the following counties:

I am generally available to do presentations at the following days/times:

SECTION 5

Order Materials

Immunizations Work Poster:

Quantity	Language
	English Spanish

IMMUNIZE Poster:

Quantity	Language
	English Spanish

Ask At Every Visit... Poster:

Quantity	Language
	English Spanish

PA Immunization Card:

Quantity	Language
	English Spanish

Immunization Dose Counter:

Quantity

Shipping Address:

Use Section 1 Address
Use New Shipping Address (Enter Below)

Name:

Practice Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Must be in 123-456-7890 format.

Fax:

Must be in 123-456-7890 format.

SECTION 6

Request Other Information

Choose One:

I would like more information on the Immunization Education Program.

I have a question about

Please send me information about the following immunization issue:

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