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CIR: Contact Form

Citywide Immunization Registry (CIR)

Enter all information requested below by typing on the computer keyboard in the available spaces. Use the Tab button to move from box to box or use your mouse to point and click. Use your Space Bar to make checks within the boxes. After all of the information is entered, use the Send button at the bottom of the page to submit the form

Facility Information
Facility Name 
Facility Code 
Phone 
Extension 
FAX 

Address 
Address Line 2 
City 
State 
ZIP 

First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
2. Administrative Contact
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
3. MIS Contact
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
4. Registry Contact
 Same as Medical Contact
 Same as Administrative Contact
 Other (please specify):
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
5. Director of Pediatrics (if applicable)
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
6. Nursing Director Neonatology (if applicable)
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
7. Director of Ambulatory/Outpatient Pediatrics (if applicable)
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Use Other (please specify):
Phone 
Extension 
FAX 
8. Chief Executive Officer (if applicable)
First Name 
Last Name 
Suffix (MD, etc) 
Title 
Email 
Same as Facility Address
Other (please specify):
Address 
Address Line 2 
City 
State 
ZIP 
Phone Same As Facility Phone plus Ext.
Use Other (Please specify):
Same As Facility FAX
Other (please specify):
Phone 
Extension 
FAX 
Listen to and enter into the text field the digits you hear

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or
Print and FAX the form to (212) 676-2314
--or--
Print and MAIL the form to:
Citywide Immunization Registry
42-09 28th Street, 5th Floor, CN 21
Long Island City., New York 11101-4132
--or--
CALL (347) 396-2400

Last Updated 1/30/13