New Jersey Immunization Information System

USER ENROLLMENT AND TRAINING REQUEST:

EARLY HEARING DETECTION AND INTERVENTION PROGRAM

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. Please print legibly or type.

Fax the completed form to the Early Hearing Detection and Intervention Program at 609-633-7820 or send via email to EHDI@doh.state.nj.us.

PART 1. USER INFORMATION
Name:	Telephone No.:
Title:
Email Address:
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:
Site City, State, Zip:
Telephone No.:	Fax::
Signature of Site Administrator:
Date:

For Internal Use Only

User ID: ______________________________	Assigned By: ____________________________

Initial Password: _______________________	Date Set Up: _____________________________

Date Trained: _________________________	Other: __________________________________

IMM-35

SEP 06

IMM-35, User Enrollment and Training Request, EHDI Program

IMM-35, user enrollment, training request, early hearing detection and intervention program, ehdi program, EHDI, NJIIS, registry

EWhite

2006-09-06

NJDHSS