Kansas Immunization Registry (KSWebIZ) Provider HL7 Questionnaire
General Information
*
1.
Facility Name:
(Required.)
*
2.
Name of Facility Contact Completing the Survey:
(Required.)
*
3.
Role of Facility Contact Completing the Survey:
(Required.)
*
4.
Email Address of Facility Contact Completing the Survey:
(Required.)
*
5.
Phone Number of Facility Contact Completing the Survey:
(Required.)
*
6.
EHR Company:
(Required.)
*
7.
EHR Product:
(Required.)
*
8.
EHR Contact Name:
(Required.)
*
9.
EHR Contact Email:
(Required.)
*
10.
Will you be submitting immunization data to WebIZ via HL7 (VXUs)?
(Required.)
Yes
No
