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New Jersey Immunization Information System

User Enrollment and Training Request

Complete one (1) form per individual attending training.
Part 1 should be filled out by the individual attending training.
Part 2 should be filled out by a Site Administrator (site manager, health officer, etc.).

All personnel to be trained must be pre-registered.


Part 1. User Information
Name:

Telephone Number:
--
Title:

Email:

Prior to attending a NJIIS training session, all users should have basic computer skills which include use of the keyboard and mouse and also have a basic understanding of Windows and the Internet.

Part 2. Your Site Information
Site Provider Name:

County:

Site Administrator Name:

 
Site Address:
City:
State:
Zip:
 
Telephone Number:
--
Fax Number:
--

To be filled out by the Site Administrator:
(Please check the appropriate level of access for the above user.
General Reader
Can only view patient information and run basic reports.
General User
Can modify or add information to existing patients, maintain inventory control records and run reports.
Site Manager:
Can modify or add information to existing patients, add new patients and modify critical fields, perform outreach, maintain inventory control records and run reports.


   

 

This system is restricted to authorized users. Random audits are routinely performed.
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