Department of Public Health



Immunization Coalition of Los Angeles County (ICLAC)

ICLAC Member Registration Form

Benefits of ICLAC Membership

Registering as a member of ICLAC will give you and your organization access to a variety of benefits:

✓ Have your organization’s name listed on the ICLAC letterhead, brochure, and other marketing materials (Executive membership)

✓ Receive regular immunization and vaccine-preventable disease email updates from the Los Angeles County Department of Public Health (Basic membership)

✓ Enhance leadership skills by participating on ICLAC workgroups and Steering Committee

✓ Have opportunities to partner with other immunization stakeholders in LA County that share your immunization-related goals/interests

✓ Receive technical assistance from ICLAC on your organization’s immunization-related projects and services

By becoming a member you can assist ICLAC in carrying out our mission which is to foster collaborative efforts to prevent vaccine preventable diseases across the lifespan. ICLAC’s mission is driven by four guiding principles:

✓ Collaborate across organizations to maximize outreach to communities at risk for vaccine preventable diseases

✓ Educate health providers to promote useful and timely public and provider information

✓ Improve access to immunizations across the lifespan to decrease health disparities

✓ Foster creativity and respect for diverse ideas

Immunization Coalition of Los Angeles County (ICLAC)

ICLAC Member Registration Form

Mission: “To Foster Collaborative Efforts to Prevent Vaccine Preventable Diseases”

| INDIVIDUAL INFORMATION |

| Name: | | |

| Last: __________________ First:__________________ Middle Initial:____ |

| |

|Title/Position:______________________________________ |

| |

|Telephone: __________________ Fax Number:____________________ |

| |

|E-mail Address:_________________________________ |

| AGENCY INFORMATION (IF APPLICABLE) |

| |

|Agency Name:___________________________________________________ |

| |

|Agency Address:____________________________________ |

| |

|City:_________________________ State:_______ Zip Code:______________ |

| |

|Check if information is the same as individual contact information ___ |

| |

|Agency Telephone:________________________ Agency Fax Number:_____________________ |

| |

|Agency E-mail Address:___________________________________ |

| |

| SERVICE PLANNING AREAS (SPAs) of interest |

| |

| ___ SPA 1 ___ SPA 2 | |___ SPA 3 ___ SPA 4 |

| | | | | |

| | | | | |

| | | |

| ___ SPA 5 ___ SPA 6 | |___ SPA 7 ___ SPA 8 |

| | | |

| |

In order to keep ICLAC unified and strong within LA County, please check the membership category your organization wishes to hold within ICLAC as defined by the categories listed below:

⇨ Basic Member – Level 1:

Designee attends general session meetings at least once per year.

⇨ Active Member – Level 2:

Designee serves as a participant on at least one ICLAC project workgroup per year.

Designee attends 3 out of 4 quarterly general session meeting throughout the year.

⇨ Executive Member – Level 3:

Designee chairs or co-chairs an ICLAC project workgroup

Designee serves on ICLAC’s Steering Committee at least once every 3 years

Organization leverages resources to help support ICLAC projects/workgroups.Rev.06/17/2010lr

ICLAC Member Workgroups, Services and Interest

| AREAS OF SERVICE |

| Please check your agency’s service type as it relates to caring for medically underserved communities (check all that apply): |

| |

| __Adolescent Immunization |__Infant Immunization |__Program Evaluation |

| __Adult Immunization |__Leadership Development |__Reproductive Health |

| __Advocacy/Legislation |__Medical Care/Health Services |__Research/Data |

| __Collaboration/Coalition Building |__Mental Health |__Social Services |

| __Community Outreach & Education |__Nutrition |__STI’s/HIV Issues |

| __Education/Provider Education |__Obesity |__Substance Use |

| __Financial Well-Being |__Physical Activity |__Youth Development |

| __Foster Care |__Policy Development | |

| __Homelessness |__Poverty Related Issues | |

| __Housing |__Program Development | |

| Other Areas of Service : |

|___________________________________________________________________________________________ |

|___________________________________________________________________________________________ |

| ISSUES OF INTEREST |

| What are the top four issues of interest you might be interested in as a member of the Immunization Coalition of LA County (check no more than four) : |

| __Access to Care |__Infant Immunization | __Research/Data |

| __Adolescent Immunization |__Provider Education | __STI’s/Issues |

| __Adult Immunization |__Leadership Development | |

| __Advocacy/Legislation |__Medical Care/Health Services | |

| __Collaboration/Coalition Building |__Policy Development | |

| __Community Outreach & Education |__Program Development | |

| __Homelessness |__Program Evaluation | |

| |

|Other Issues of Interest: __________________________________________________________________________________________ |

|___________________________________________________________________________________________ |

| Would you be interested in participating in an ICLAC issue-based Workgroup? |

| __Yes __No |

| If yes, check the following subcommittees of interest: |

| |

|Advocacy: The advocacy workgroup seeks to address immunization barriers and disparities across the lifespan through legislative advocacy and policy |

|development. Maximum hours spent per month: 2 to 4 (or as needed). Status: inactive. |

|Health Care Worker Influenza Immunization Initiative: This workgroup has conducted a survey amongst acute care hospitals in LA county to better understand |

|the policies and practices around influenza vaccinations for employees. Maximum hours spent per month: 2 to 4 (or as needed). Status: Active. |

|National Adult Immunization Awareness Week (NAIAW): A workgroup that collaborates with immunization stakeholders to develop annual NAIAW community and |

|provider awareness events that bring focus to the importance of adult immunizations across the lifespan. Status: Inactive |

|IFAN (Immunization For Adults Now): This workgroup is currently active and collaborating on a community needs assessment to assess the availability of adult|

|vaccines at community clinics that serve homeless, uninsured, and low income adults. Status: Active |

|Steering Committee: The Steering Committee functions as the executive decision-making body for ICLAC. Members rotate leadership responsibilities and provide|

|policy and fiscal oversight over ICLAC and its organizational activities in the community. Maximum hours spent per month: 2-4 hrs (or as needed). Status: |

|The workgroup is active and meets as on an as needed basis. |

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TO REGISTER

Complete the attached registration form and send it by mail or e-mail to:

Wendy Berger, MPH

Immunization Coalition of Los Angeles County

3530 Wilshire Boulevard, Suite 700

Los Angeles, CA 90010

Phone: 213-351-7499

wberger@ph.

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Rev.3/9/11 wb

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