Exit this survey Arizona Regional Extension Center Roadshow Registration 1. Participant Information Question Title * 1. Please provide the following information: Name: * Company: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: * Question Title * 2. What is your role in health information technology? Physician Other Provider (PA, NP, RN, etc.) Hospital Staff Office/Practice Manager Billing Specialist Office Staff IT Consultant Educator EHR Vendor Other Question Title * 3. If other, please specify: Question Title * 4. Practice Contact Information (please fill out if affiliated with a medical practice) Phone Number: Fax Number: Office Manager: Email Address: Question Title * 5. If you are affiliated with a medical practice, what specialties are offered? Family Practice General Practice Geriatrics Gynecology Internal Medicine OB/GYN Pediatrics Other Question Title * 6. If other please specify: Question Title * 7. If you are affilited with a medical practice, does the office have an electronic health records (EHR) system? Yes No Question Title * 8. If yes, what software is used? Question Title * 9. May we share your information with our event sponsor? Yes No Next