Online Survey Software | Qualtrics Survey Solutions

Instructions: Providers who wish to participate in the Vaccines for Children Program should complete the following enrollment survey. On the final page providers should print the entire survey to keep a copy for their records.

IMPORTANT: The final page of the survey MUST be signed by the Medical Director and returned to the Immunization Unit via email to vaccine@nd.gov.

Facility Name

Is the listed name of your facility accurate?

Yes
No, please update to:

Facility Type

Facility Contact Information

<span style="font-size:16px;">Facility Contact Information</span>
	Street	City	County


	Address
Facility Address		City - Facility Address	County - Facility Address

Facility Contact Information, Cont.

<span style="font-size:16px;">Facility Contact Information, Cont. </span>
	State	Zip Code	Phone Number	Fax Number


		XXXXX only	(xxx)xxx-xxxx	(xxx)xxx-xxxx
Facility Address	State - Facility Address

Shipping Address (if different than facility address)

<span style="font-size: 16.3636360168457px;">Shipping Address (if different than facility address)</span>
	Shipping	City	State	Zip


	Address			Code
Mailing Street Address		City - Mailing Street Address	State - Mailing Street Address

Survey Completion
0%	Current Progress 0%	100%