You Can Stop the Flu
Success Story Submission Form

Please share your success with your colleagues. Submit the information below and we'll work with you to make the appropriate parts of your success story available online so that others can learn from your work.

First Name   Last Name
 
Title   Facility Name
 
City   State
 
Email   Phone

I would like to share my success story but do not have time to enter the information at this moment. Please contact me at the email address above to follow-up.

Program Summary
Please summarize your successful influenza immunization program for health care workers using the box below.
 
Your Role
What was your role in the program?
 
Pearls
Please provide any pearls.
 
Example Materials
Are you able to share any of your materials (e.g., forms, PowerPoint presentations, flyers) to assist other pharmacists with their programs?
 
Outcomes
If desired, please indicate the change in your health care worker influenza immunization rate as a result of the program.
 
Additional comments
 
Verification Question
What month is it? Hint: January, February