Program Practices Submission Form Program practices submission form - immunization program practices information Immunization Program Practices InformationFill out and submit this form offline by downloading the form here.NameAs you want it to appear publicly Email address ProgramAs you want it to appear publicly Does AIM have permission to share this information on the publicly accessible AIM website?All materials submitted will be posted on the AIM website. Yes No Bull's-Eye AwardThe Bulls-Eye Award for Innovation and Excellence in Immunization recognizes immunization strategies that “hit their mark” and achieve immunization goals with special consideration for practices that are innovative and easily replicated. Each year, AIM awards three programs the Bull’s-Eye Award. Only those practices with activities that are currently ongoing or concluded January 2018 through the present (including implementation, follow-up, and/or evaluation activities) will be considered for the award. Would you like for this submission to be considered for the 2019 AIM Bull’s-Eye Award? Yes No Program Practice InformationTitle KeywordsProvide up to 5 main terms or phrases that describe the practice.Is this practice evidence- or guideline-based?If yes, please include reference below. Yes No Reference BackgroundDescribe the scope of the immunization need or problem.Program Practice DescriptionDescribe the practice goals and objectives.What were the main implementation activities?Where and when did the practice take place?How much staff time was involved?Identify the target population that the practice affected.What were the costs associated with the activity? What was the funding source?If partners were involved, include who was involved, and how?Timeframe of Implementation (Start and stop dates) Evaluation Data: Was the implementation and/or effectiveness of this practice assessed?If "yes" or "limited" provide any data that is available Yes Limited No Data Conclusions/Lessons Learned/Key Factors for SuccessCheck if any of the following are being submitted to complement your submissionAll materials will be posted on the AIM website Testimonials Quote from partner/participant Sample of materials produced Press release Promotional materials Project photo(s) Publication (e.g. news story, journal article) Video/audio clip Website URL Tables or graphs Other (explain below) Complementary FilesUpload any files to complement your submission Drop files here or Select files Max. file size: 2 MB. PhoneThis field is for validation purposes and should be left unchanged.