New Jersey Department of Health

Vaccine Preventable Disease Program

P.O. Box 369, Trenton, NJ 08625-0369

www.njiis.nj.gov

NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)

“INSURED FOR SURE” USER ENROLLMENT

Complete one (1) form per individual.

Part 1 should be filled out by the individual; part 2 should be filled out by a Site Administrator (site manager, health officer, etc.).

Please print legibly or type.

Fax the completed form to 609-341-5098.

PART 1. USER INFORMATION
Name:	Telephone No.:
Title:	Email Address:
Address:
City, State, Zip Code:
PART 2. YOUR SITE INFORMATION
Site Name:	County:
Site Address:
Site City, State, Zip:
Telephone No.:	Fax::
Site Administrator Name (Print):	Email Address:
Site Administrator Signature:
Date:

For INTERNAL Use Only
User ID: ______________________________	Assigned By:	______________________________

Initial Password: _______________________	Date Set Up:	______________________________

Date Trained: _________________________	Other:	___________________________________

IMM-31

JUL 12

IMM-31, Insured for Sure User Enrollment

IMM-31, User Enrollment, immunization, NJIIS, IMM, vaccine preventable disease program, VPDP

Elaine White

2010-01-07

ewhite

NJDOH