1. Are you currently a Wyoming Vaccinates Important People (WyVIP) Provider?	Yes No
If you answered yes, please provide your WyVIP Pin here:
2. Please enter the name of your clinic/organization/business:
3. Please enter the name of the person completing the survey:
4. Please enter the title of the person completing the survey:
5. Type of organization:	Public Health Clinic Doctor's Office Federally Qualified Health Ctr (FQHC)/Community Health Ctr Migrant Health Clinic Rural Health Clinic (RHC) Hospital Pharmacy Other (Please indicate below)
If you indicated other above, please list type:
6. Contact Information. Mailing address:
City:
State:
Zip:
Phone:
Fax:
Contact e-mail address:
7. Preferred Contact Method:	Phone Fax E-mail USPS
8. Would you be interested in administering the H1N1 flu vaccine to your patients, if a vaccine is offered?	Yes No
9. Is your office currently authorized to access and enter immunization information into the Wyoming Immunization Registry (WyIR)?	Yes No
10. Does your office currently have Internet access?	Yes No