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ATTACHMENT C <br />Washington State Immunization Information System <br />System User Access Account for Exchange of Immunization Data <br />Provider/Plan Name ______________ Contract# ______ _ <br />This worksheet Is to request user accounts to access IIS Immunization Data under the above Information <br />Sharing Agreement. Make add itional copies of this form if needed . Fill in the requested information for each <br />principal or employee who will need access lo I IS Immunization Data, then fax the form to 360-263-3590. <br />Each person must create a Login ID of all letters, all numbers, or a combination of letters and numbers AT <br />LEAST four characters long (but can be longer). Login IDs are not case sensitive . 11S will provide a temporary <br />password for each user. The system will prompt for a new password upon logging in the first time . <br />Questions? Please contact our Help Desk at 1-800-325-5599 or via email atWAIISHelpDesk@doh.wa.gov. <br />Login ID : ____________ (al leas/ 4 charact6rs) Office Phone (__J __ -___ Ext. __ _ <br />Office Email:~ ___________________ Credentials, if ru,y: _____ (e.g .. MA, RN) <br />First Name: _____________ _ Last Name: ________________ _ <br />Clinic Site(s): _________________________ _ <br />Does user float between more than one clinic? _yes _no Does the user administer vaccines? __yes _no <br />Login ID; ____________ (at /errs/ 4 characters) Office Phone L_) __ -___ Ext. __ _ <br />Office Email : ____________________ Credentials, if ony :. _____ (e.g .. MA, RN) <br />First Name: Last Name: ________________ _ <br />Clinic Site(s): __________________________________ _ <br />Does user float between more than one clinic? __yes _no Does the user administer vaccines? _yes _no <br />Login ID: ____________ (at least 4 characters) Office Phone (__J __ -___ Ext. <br />Office Email: ____________________ Credentials, ifany:c_ ____ (e.g., MA, RN) <br />First Name: _____________ _ Last Name: ________________ _ <br />ClinicSite(s): ___________________________________ _ <br />Does user float between more than one clinic? __ yes _no Does the user administer vaccines? __yes _no <br />Page 8 of8 <br />If you have a disability and need this document in another format, please call l-800-525-0127 (711-TTY relay). <br />DOH 348-576 November 2017