"Show Me: Immunization Edition" Application

"Show Me: Immunization Edition" Application
The NCPA Innovation Center is creating a new video series designed to help pharmacies improve and expand their immunization services. Modeled after popular reality TV shows, we are looking to identify several pharmacies who want help from an expert peer successful in offering immunization services and how to overcome common challenges and barriers faced when trying to improve vaccination rates.

Pharmacy Information
NCPA Member ID *
Applicant Name *

First Name Last Name
Applicant Email *
example@example.com
Applicant Phone Number *
Please enter a valid phone number.
Owner Name (if different from applicant)

First Name Last Name
Owner Email
example@example.com
Owner Phone Number
Please enter a valid phone number.
Pharmacy Name *
Pharmacy Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pharmacy Phone Number *
Please enter a valid phone number.
Pharmacy Website
Pharmacy Social Media
Provide Facebook, Instagram and LinkedIn information if applicable
Please select the population density that most appropriately describes where your pharmacy is located. *
Describe the general demographics of your patient base. *
What pharmacy management system(s) do you use? *

Staff Information
How many pharmacists do you employ? *
How many employed pharmacists are immunization certified? *
How many technicians do you employ? *
How many employed technicians are immunization certified? *
How many additional staff do you employ and what are their general roles/titles? *
Do you have students and/or residents who rotate through your pharmacy? *

Yes No
If yes, how many students and/or residents do you have at any given time?

Filming Information
Have you ever been on television or done any public speaking before? *

Yes No
Would you have any issues explaining publicly areas of your business that may need improvement? *

Yes No
Are there any parts of your business that you do not want to show on camera or describe? *

Yes No
If yes, please explain.
Will you need to get anyone else's permission to have a film crew shooting outside and inside of you business (e.g., landlord, property manager, etc.) *

Yes No

How did you hear about this project? (Select all that apply)

Electronic communication (qAM, email, etc.) Social media (Facebook, LinkedIn, etc.) Colleague/Friend
Should be Empty:

Pharmacy Information