New Jersey Department of Health

Vaccine Preventable Disease Program

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

609-826-4860 (Fax 609-826-4866)

www.njiis.nj.gov

NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)

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.

All personnel to be trained must be pre-registered. Please print legibly or type.

Fax or mail the completed form to your local Maternal and Child Health Consortia (MCHC) office or the Vaccine Preventable Disease Program, at the address listed above. Information for the local MCHC for your county can be found at www.njiis.nj.gov/njiis/jsp/trainingschedule.

PART 1. USER INFORMATION
Name:	Telephone No.:
Title:	Email Address:
Address:
City, State, Zip Code:
How do this user’s job tasks relate to NJIIS?
NOTE:	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. NJIIS SITE INFORMATION
Site Name:	County:
Site Address:
Site City, State, Zip:
Telephone No.:	Fax::
To be completed by Site Administrator:

Please check (() the appropriate level of access for above authorized user.

General Reader:

Access to view patient information and to run standard reports.

General User:

General Reader access and access to modify or add information to existing patient records, add new patients, perform inventory and perform outreach functions to patients for whom the designated agent’s NJIIS site has primary responsibility.

Site Manager:

General User access and access to modify critical fields and maintain inventory control records.

School/College General Reader:

Access to view student information and to run standard reports.

School/College General User:

General Reader access and access to modify or add information to existing student’s records, add new students, and perform outreach functions to students for whom the designated agent’s NJIIS site has primary responsibility.

VFC Data Entry Only:

Access assigned by VFC Program only for vaccine accountability.
Site Administrator Name (Print):	Email Address:
Site Administrator Signature:
Date:

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

Initial Password: _______________________	Date Set Up:	______________________________

Date Trained: _________________________	Other:	___________________________________

IMM-41

JUL 12

IMM-41, User Enrollment and Training Request

IMM-41, User Enrollment, Training Request, immunization, NJIIS, IMM, vaccine preventable disease program

Elaine White

2007-08-01

ewhite

NJDOH