Immunization Certificate Template by kjj16796


Immunization Certificate Template document sample

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									                               SNPHA hosting:
                        Friday July 23, 2010 | 12-4 p.m.
                                    Renaissance Hotel
                           515 Madison Street | Seattle, WA 98104

This program is designed specifically to train pharmacists and pharmacy students to participate in an
Immunization program for adults and adolescents. The content derived from the CDC program
"Epidemiology & Prevention of Vaccine-Preventable Diseases" and adapted to Washington State specific
pharmacy law and practice. By completing this course, pharmacists can earn 15 hours of continuing education
credit while becoming certified to administer adult and adolescent vaccines.
Epidemiology and Prevention of Vaccine-Preventable Diseases
Faculty: Iyabode Akinsanya-Beysolow, MD, MH, FAAP, Medical Officer, CDC, NCIRD, William Atkinson,
MD, MPH, Medical Epidemiologist, CDC/NCIRD, Andrew Kroger, MD, MPH, Medical Officer,
CDC/NCIRD, Mona Saralya, MD, MPH, Medical Officer, CDC/NCIRD, Donna Weaver, MN, RN, Nurse
Educator, CDC/NCIRD and Target Audience Content Expert, Angela Calcugar, MD, MPH, Epidemic
Intelligence Service Officer, CDC.
ACPE# 0130-9999-09-039-H04 P | 12 hours home study | 1.20 CEUs |Initial release date 7/1/2009 |
Expiration date 7/1/12 | Activity Type: Knowledge
The didactic training is designed for pharmacists to improve immunization practices in the United States.
Participants will view the DVD’s which is approximately 10 hours of a satellite broadcasts. The didactic
home study will require use of the text: Epidemiology & Prevention of Vaccine-Preventable Diseases,
published by the CDC. An open-book post-test must be completed with a score of at least 70% correct
responses. Pharmacists will receive a Statement of Credit for a total of 12 hours or 1.20 CEUs within 4-6
weeks after sending in the answer sheet.
Participants will receive the CDC Epidemiology and Prevention of Vaccine-Preventable Diseases Didactic
and the Immunization Works 2009 CD. The Immunization Works 2009 CD includes valuable tools to set up
your vaccine practice including Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book)
11th Edition, The easy-to-reference Pink Book contains updated, comprehensive information on each
vaccine-preventable disease, as well as the latest information on principles of vaccination, general
recommendations on immunization, immunization strategies for healthcare practices and providers and
vaccine safety.
Vaccinating Adults & Adolescents: An Immunization Program Practicum Session
Faculty: Jenny Arnold, Pharm.D., Director of Pharmacy Practice Development, Washington State Pharmacy
ACPE# 0130-0000-10-010-L04 P (3 hours live | 0.3 CEUs) | Initial release date 6/1/10 | Expiration date
Activity Type: Application
The practicum session involves hands-on training about pharmacist provision of immunizations. The
practicum covers how to establish an immunization program in your pharmacy, collaborative drug therapy
agreements, protocols, documentation forms, updated guidelines, vaccine storage and handling, work flow
tips, and reimbursement. Participants give and receive injections and prepare for adverse events. The live
practicum is accompanied by the text, Immunization: a Manual for Pharmacists, published by WSPA. This
manual includes review of WA State pharmacy laws authorizing administration of vaccines, a collaborative
prescribing protocol template, international travel vaccine recommendations, screening tools, protocols for
management of anaphylactic reactions, WA Dept of Health administration consent records, vaccine
administration guidelines, reporting, and financial considerations and reimbursement.
No partial credit will be given. Registrants must sign-in, attend the program and complete and submit the
official evaluation form at the end of the program to receive credit. Pharmacists will receive a total of 3 hours
or 0.3 CEUs for completion of this part and the statement of credit will be mailed within 4-6 weeks after the
date of the program.

PART 3 – CPR (External, on your own)
In order to receive an immunization certificate, you must have a current adult CPR card. CPR training is not
included in this program. If your CPR card is not up-to-date, please complete CPR training and provide proof
of CPR certification to the WSPA.

Immunization Certificate of Completion:
In order to receive your certificate of completion for the Immunization training program, you must
successfully complete all three parts of the immunization program within one year of the practicum date. The
steps do not need to be completed in succession. Formal Certificates will be mailed by WSPA upon
successful completion of the program in its entirety in the case these parts are not met by the national
conference in Seattle, Washington.

     The Washington State Pharmacy Association is accredited by the Accreditation Council for
     Pharmacy Education as a provider of continuing pharmacy education.

     Registration Deadline is June 4, 2010.
     The registration includes “Immunization: a Manual for Pharmacists”, CDC Epidemiology and Prevention of
      Vaccine-Preventable Diseases Didactic (set of 4 DVDs) and The Immunization Works 2009 CD
      containing the post test, statement of credit and a formal immunization certificate. Registration is taken
      on a first-come basis.
     Please read in its entirety the notification of agreement form making sure to complete each part of the
      immunization training program.

                                          Please email completed form:
                              Phone: 210.88.1066  Mail:
    Once the registration form has been received a set of the home study DVD’s will be sent via mail as well as
                                              the post-test via email.
                                          Notification of Agreement
 I, _____________________________ (print name), am fully aware that SNPhA has agreed to sponsor my
 registration to participate in the Washington State Pharmacy Association’s Immunization Program for
 adults and adolescents. Participation in this program is contingent upon receipt of the following:
 completed Registration Form, signed Notification of Agreement form, and full payment of the registration

 In order to complete the program and receive my immunization certificate in Seattle, Washington, I am
 aware that the following must be completed and submitted to National Office (
 by July 16th.
         - Completed immunization post-test (>70%)
         - Practicum (completed at national convention)

 The Immunization program will provide me with training to administer immunizations both safely and
 appropriately, to identify patients who may be candidates for select immunizations, as well as to educate
 patients on the different immunizations. However, I understand that in order to become an immunizing
 student pharmacist, I must meet the requirements set forth by the board of pharmacy in the state in which
 I intend to administer immunizations. I also understand that completion of the Immunization program
 provided by the Washington State Pharmacy Association during the National Convention in Seattle,
 Washington may not, in and of itself, permit me to administer immunizations in the state in which I
 intend to administer immunizations. I am responsible for contacting my state board of pharmacy to
 determine what additional requirements, if any, I must completed before I am able to administer

 I am aware that I have until June 25th to cancel my registration in the immunization program. Otherwise,
 it will be assumed that I will be in attendance at the immunization training on July 23rd at 12 noon,
 schedule flights accordingly.

 By signing below, I have agreed to all of the above and would like for my name to be considered for one
 of the first 150 members SNPhA will sponsor to participate in the Washington State Pharmacy
 Association’s Immunization Program at the National Convention in Seattle Washington. This form should
 be scanned and emailed to (

 ________________________________                         _____________                  __________________________
 (Signature)                                              (Date)                         (Chapter)

 City| ST | Zip: ________________________________________________________________________________
 Phone: _______________________________              Pharmacy School________________________________________

If you have questions, please contact Trey Rumph, SNPhA Operation Immunization Chair at: or 423-313-5399. If you need to cancel registration contact

   ®             The Washington State Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a
                 provider of continuing pharmacy education.

 Office Use Only: DVD’s mailed out __________Practicum CE sent: __________ Didactic post test completed: ____________
 Didactic CE sent: _______ CPR card on file: ___________ Certificate sent: ___________
                   Immunization Program Check List

Completed Registration for Conference

Completed Notification of Agreement

Complete Didactic post-test and submitted

Proof of BLS/CPR training scanned in and submitted

                           Attach a front copy of BLS/CPR proof

Please submit the Check List along with your completed documents to facilitate
                       processing of your registration.

                                  Thank You!

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