Application - New York University



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Thank you for your interest in having your student health center team join the National College Health Immunization Collaborative, a quality improvement collaborative focused on increasing immunization rates among college students. We will first ask several screening questions to make sure your student health center team is eligible to participate. If eligible, the full application will continue automatically.  

[If eligible, continue to Full Application]

Congratulations!  Your student health center team is eligible to participate in the National College Health Immunization Collaborative.  

Enrollment includes the following steps:  

1. Submit this application to help determine your team’s readiness for participation by September 15, 2017.  Note: a completed application is NOT a binding agreement to participate. 

2. *Optional*.  You may request a call with a member of the Collaborative faculty to discuss your application and any remaining questions you may have about participating by emailing us at immunizationqi@nyu.edu or (212) 443-1036.

3. Sign and return an institutional letter of commitment by October 1, 2017    

Please note the following: You must complete the application in one session. We strongly encourage you to preview the application, using the downloadable document. You may want to gather any necessary data and write your responses in a text application such as MS Word before filling out the online application form (you can copy and paste your responses from a text application into the online application).    

Questions? Email us at immunizationqi@nyu.edu.    

Q8 Primary Liaison for the Collaborative (may or may not be you)

Name

Title

Department

Email address

Phone number

Q9 What is the name and position of the Senior Leader who can support your team's immunization quality improvement efforts, including removing obstacles that may arise or helping your team obtain necessary resources?  Chief Student Affairs, Health and/or Administrative Officer are examples of a Senior Leader (may or may not be you).

Name

Title

Department

Email address

Phone number

Q10 Limited scholarship support is available and awarded based on availability, financial need, and firm commitment to project goals and Collaborative activities.   If you receive scholarship funding, you will be asked to accept or decline that funding within a limited period of time to allow others to receive funding that is not accepted. We ask that you respond either way.

If you are applying for a scholarship to participate, please use the space below to:  

1. indicate the amount of the $150 registration fee that your institution is able to contribute.  

2. explain your institution's financial hardship 

3. describe how the scholarship will allow your institution to participate

Q11 Explain how you think participation in the National College Health Immunization Collaborative will help increase your student health center's vaccination rates.

Q12 What is your student health center's primary motivation for joining the National College Health Immunization Collaborative? 

← Chance to benchmark college students' immunization rates with other student health centers

← Status of being part of a national college health effort

← Ability to network with other college health professionals

← Priority of senior leadership

← Priority of community partners (e.g., local hospital, department of health, city/state)

← Our data suggests that our college's immunization rates are low

← Opportunity to meet accreditation standards

← Potential to expand our quality improvement activities and capacity

← Concern arising from previous vaccine-preventable disease outbreak(s) at our college

← Concern arising from vaccine-preventable disease outbreak(s) at other colleges

← Concern arising from vaccine-preventable disease outbreak(s) in the community or nationally

← Other: ____________________

Vaccination Practices 

These next set of questions will inform us about the current vaccination practices of colleges/universities that may participate in the Collaborative, so we can tailor activities to participants' needs.

Q14 Which other vaccines, if any, does your student health center or student health office stock and administer? 

❑ Hep A (hepatitis A)

❑ Hep B (hepatitis B)

❑ IPV (inactivated poliovirus)

❑ MenACWY (meningococcal conjugate: Menactra®, Menveo®)

❑ MMR (measles, mumps, rubella)

❑ PCV13 (pneumococcal conjugate)

❑ Td/Tdap (tetanus and diphtheria toxoid with or without acellular pertussis)

❑ Var (Varicella)

❑ Other (please specify):

❑ None, we do not stock and administer any of the above vaccines

Q15 Does your state or college have an official policy that requires students to be up-to-date, show proof of immunity, or provide exemption for any vaccination(s)?

← Yes

← No ( [skip to Q17]

← I don't know ( [skip to Q17]

[If Q15=Yes, display Q16]

Q16 How does your college track each student's immunization status for required vaccination(s)? 

← Electronic Health/Medical Record (EHR/EMR) (please specify) ____________________

← Immunization specific software (please specify) ____________________

← Registrar database

← State or local registry

← Other (please specify) ____________________

Q17 Has the appropriate staff at your student health center received initial or refresher training on proper immunization storage, handling and administration techniques?

← Yes. (Please list the year in which the most recent training occurred.) ____________________

← No

← I don't know

Q18 Has the appropriate staff at your student health center received initial or refresher training on counseling students who are hesitant about vaccination?

← Yes. (Please list the year in which the most recent training occurred.) ____________________

← No

← I don't know

Q19 If applicable, describe any external resources or partnerships (e.g., department of health, vaccinators in your community) that supplement or support vaccination efforts on your campus.

Student Health Center Profile

Q21 Please estimate the Full Time Equivalent (FTE) staffing at your student health center.   For example, if you have 2 physicians, one who works 40 hours/week and the other 20 hours/week, then the # of FTE Physicians=1.5.  If you don’t know for sure, please guess:

_______ Total Full Time Equivalent (FTE) Employees for your entire student health center (including but not necessarily limited to operations, support staff, insurance, etc.)

_______ # of FTE Physician(s)

_______ # of FTE Nurse Practitioners and/or Physician Assistants

_______ # of FTE Registered Nurses

_______ # of FTE Medical Assistants

Q22 The majority of our students' immunization records are stored on:

← Paper ( Skip to Q25

← Electronic records

[If Q22=Electronic records, display Q23]

Display This Question:

If The majority of our medical records are: Electronic Is Selected

Q23 Which electronic health record (EHR) system does your student health center use?

← PNC (Point and Click Solutions)

← Medicat

← PyraMED

← Other (please specify): ____________________

College/University Profile

Q25 Where is your college/university located? If there are multiple locations, please list the main campus.

City

State

Q26 If your college/university has multiple locations, please list the city/cities and state(s) of the satellite locations.

Q27 Does your college/university have residential housing for students?

← Yes

← No

Q28 Describe the geographic make-up of your student body? You may use your best estimate.

______ are in-state students

______ are out-of-state (not international) students

______ are international students

Q29 What percentage of your college's/university's students are enrolled in the following types of insurance plans?  You may use your best estimate.  If your college/university participates in the ACHA National College Health Assessment (ACHA-NCHA), consider referencing your NCHA data to complete this item. 

______ School-sponsored Student Health Insurance Plan

______ Public insurance plan (Medicare, Medicaid, Tricare)

______ Private insurance plan (e.g., Kaiser Permanente, Blue Cross Blue Shield)

______ Uninsured

______ Other (please specify)

______ Completely unknown

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