ASIIS 2011 Survey

1. Arizona State Immunization Information System (ASIIS) 2011 Survey

Dear ASIIS user:

Please complete this survey by November 30th to be eligible for a $50 VISA Gift Certificate donated by The Arizona Partnership for Immunization (TAPI). Your answers will help us improve the program to serve you and Arizona's children better. The survey should take approximately 7 minutes to complete.

Question Title

* 1. Should you have questions related to this survey or any other ASIIS issue, please contact our office at (602) 364-3899.

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

County:

Email Address:

Question Title

* 2. Type of Practice (Please check the box that best represents your practice/facility)

Pediatrics

Family Practice

Community Health Department

Indian Health Services

School/Daycare/Headstart

Other (please specify)

Question Title

* 3. Title of person completing this form:

MD/DO

RNP

RN/LPN

Office Manager

Other (please specify)