Citywide Immunization Registry (CIR)

Enter all information requested below by typing on the computer keyboard in the available spaces. Use the Tab button to move from box to box or use your mouse to point and click. Use your Space Bar to make checks within the boxes. After all of the information is entered, use the Send button at the bottom of the page to submit the form

Facility Information

Facility Name  Facility Code  Phone  Extension  FAX

Address  Address Line 2  City  State  ZIP

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

2. Administrative Contact

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

3. MIS Contact

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

4. Registry Contact

Same as Medical Contact  Same as Administrative Contact  Other (please specify):

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

5. Director of Pediatrics (if applicable)

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

6. Nursing Director Neonatology (if applicable)

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

7. Director of Ambulatory/Outpatient Pediatrics (if applicable)

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Use Other (please specify):

Phone  Extension  FAX

8. Chief Executive Officer (if applicable)

First Name  Last Name  Suffix (MD, etc)  Title  Email

Same as Facility Address Other (please specify):

Address  Address Line 2  City  State  ZIP

Phone Same As Facility Phone plus Ext. Use Other (Please specify): Same As Facility FAX Other (please specify):

Phone  Extension  FAX

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