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The goal of this study was to categorize reasons behind missed opportunities for human papillomavirus (HPV) vaccine initiation in an under-resourced population and to identify associated patient and clinic characteristics. Manual chart review was performed for patients aged 11 to 18 years who visited a primary care clinic in a health system in Texas, USA between 06/01/18 and 08/31/18 and were due for an initial HPV vaccine dose but did not receive it. Reasons for HPV vaccine noninitiation were categorized as follows incomplete immunizat