Training Tour Registration Survey

During the months of June & July, the Indiana State Department of Health (ISDH) staff will be traveling with their vendor, ImageTrend, to train you (the EMS provider) on how to use this database as your own electronic patient care report (ePCR) registry.

Training Agenda:
- Setting up your service in the registry
- Directly inputting an EMS run
- Running reports
- Electronically submitting data

All training sessions will last 3 hours.

1. The name of the EMS provider you will be entering data for:

The name of the EMS provider you will be entering data for:

2. Who is your current software vendor?

Who is your current software vendor? I have no software vendor

Firehouse, but we want to use a NEMSIS 2 compliant vendor

Someone else but we want to reduce software costs by using the free state software

Someone else and we plan on using them for the foreseeable future

Name of current software vendor

3. Your name:

Your name:

4. Your email address:

Your email address:

5. Which training date are you planning on attending?

	9:00am-12:00pm	1:30pm-4:30pm
Monday, June 17: Terre Haute Landsbaum Center for Health Education 1433 North 6 1/2 Street	*Which training date are you planning on attending? Monday, June 17: Terre Haute Landsbaum Center for Health Education 1433 North 6 1/2 Street 9:00am-12:00pm	Monday, June 17: Terre Haute Landsbaum Center for Health Education 1433 North 6 1/2 Street 1:30pm-4:30pm
Tuesday, June 18: Evansville Welborn Room Health Department 410 Mulberry Street	Tuesday, June 18: Evansville Welborn Room Health Department 410 Mulberry Street 9:00am-12:00pm	Tuesday, June 18: Evansville Welborn Room Health Department 410 Mulberry Street 1:30pm-4:30pm
Wednesday, June 19: Scottsburg Mid America Science Park 821 South Lake Road	Wednesday, June 19: Scottsburg Mid America Science Park 821 South Lake Road 9:00am-12:00pm	Wednesday, June 19: Scottsburg Mid America Science Park 821 South Lake Road 1:30pm-4:30pm
Thursday, June 20: Columbus Columbus Learning Center 4555 Central Avenue	Thursday, June 20: Columbus Columbus Learning Center 4555 Central Avenue 9:00am-12:00pm	Thursday, June 20: Columbus Columbus Learning Center 4555 Central Avenue 1:30pm-4:30pm
Friday, June 21: Indianapolis Government Center South - Conference Room B 420 West Washington Street	Friday, June 21: Indianapolis Government Center South - Conference Room B 420 West Washington Street 9:00am-12:00pm	Friday, June 21: Indianapolis Government Center South - Conference Room B 420 West Washington Street 1:30pm-4:30pm
Monday, July 22: Muncie Open Door Health Services Community Room 333 South Madison	Monday, July 22: Muncie Open Door Health Services Community Room 333 South Madison 9:00am-12:00pm	Monday, July 22: Muncie Open Door Health Services Community Room 333 South Madison 1:30pm-4:30pm
Tuesday, July 23: Fort Wayne Public Safety Academy 7602 Patriot Crossing	Tuesday, July 23: Fort Wayne Public Safety Academy 7602 Patriot Crossing 9:00am-12:00pm	Tuesday, July 23: Fort Wayne Public Safety Academy 7602 Patriot Crossing 1:30pm-4:30pm
Wednesday, July 24: Mishawaka ED/EMS Conference Room 5215 Holy Cross Parkway, Mishawaka, IN 46545	Wednesday, July 24: Mishawaka ED/EMS Conference Room 5215 Holy Cross Parkway, Mishawaka, IN 46545 9:00am-12:00pm	Wednesday, July 24: Mishawaka ED/EMS Conference Room 5215 Holy Cross Parkway, Mishawaka, IN 46545 1:30pm-4:30pm
Thursday, July 25: Crown Point Crown Point Community Library 122 North Main Street	Thursday, July 25: Crown Point Crown Point Community Library 122 North Main Street 9:00am-12:00pm	Thursday, July 25: Crown Point Crown Point Community Library 122 North Main Street 1:30pm-4:30pm
Friday, July 26: Lafayette YWCA 605 North 6th Street	Friday, July 26: Lafayette YWCA 605 North 6th Street 9:00am-12:00pm	Friday, July 26: Lafayette YWCA 605 North 6th Street 1:30pm-4:30pm

6. List the names of the those that will be attending this session with you:

List the names of the those that will be attending this session with you: 1
2
3
4
5
6

7. Do you have any questions or concerns?

Do you have any questions or concerns?