Immunization Registry Survey  (Please complete only if you provide immunizations)

1. Please provide your contact information (Required fields)
2. What is your organization type?
3. Does your office have access to the Internet?
4. Does your organization currently have a system to capture information electronically about immunizations administered?
5. Which best describes the electronic system that you use?
6. If you use an electronic system, do you see it listed here? Please select the one that fits the system you use best.
7. If you do not have a certified Electronic Health Record, do you plan to purchase or upgrade to one?
8. How do you plan to submit your immunization data to the Registry? Please check all that apply.
9. If you are currently submitting data directly to the Registry but plan to change the submission method, please check the option you plan to use.
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