Kansas Immunization Registry (KSWebIZ) Provider HL7 Questionnaire

General Information

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* 1. Facility Name:

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* 2. Name of Facility Contact Completing the Survey:

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* 3. Role of Facility Contact Completing the Survey:

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* 4. Email Address of Facility Contact Completing the Survey:

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* 5. Phone Number of Facility Contact Completing the Survey:

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* 6. EHR Company:

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* 7. EHR Product:

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* 8. EHR Contact Name:

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* 9. EHR Contact Email:

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* 10. Will you be submitting immunization data to WebIZ via HL7 (VXUs)?

Yes

No