HPV QI Program Wave 2 – Site Questionnaire

HPV QI Project Wave 2 - Site Visit Questionnaire

Provider Name: *

VFC/Assigned Number:

Street Address: *

City & ZIP: *

Phone: *

Fax:

Primary Contact Name: *

Primary Contact Email: *

Secondary Contact Name:

Secondary Contact Email:

Provider Type *

Local Health Department

Private

FQHC

Typer of Medical Records used by Providers *

Paper (only)

Electronic (EHR, ImpactSIIS, etc.) (only)

Combination of Paper and Electronic

Method Provider Reports to ImpactSIIS *

Direct Data Entry via Web Interface (EHR is sent to ImpactSIIS, HL7)

Electronic Submission (provider directly hand enters data into ImpactSIIS)

Provider does not submit data to ImpactSIIS