ASCIInc Marketing Survey

1) Please tell us about yourself

 

Your First Name:
Your Last Name:
Office Telephone Number:
Practice or Office Name:
Address/Location:
Personal EMail Address:

Please do not distribute my name to email lists other than for ASCIInc.

2) Please tell us about your proposed use of ASCIInc's products or services

• Where did you learn of ASCIInc products or services information?


• In which industry will you use ASCIInc product or service? (Check all that apply)

Private Medical Office
Government Clinic
Government Hospital
Educational Institution Infirmary
MIS Services Department
Research Institution
Military Facility
Pharmaceutical Company
Statistical Data Mining or Information Gathering Organization
Other (please specify): 

3) Please tell us about your plans to use the Cybermed Immunization System

• Are you concerned about missed opportunities for immunization?


• My office assigns the reporting and preparation of immunization reports:

In our officeAt another locationOther (please specify): 
• My office spends approximately (how many?) hours each week preparing immunization reports:?

0 - 3 Hours 4 - 6 Hours 7 - 10 Hours More than 10 Hours
• The above time is spent (please check all that apply):

Locating information that pertains to specific relatives, responsible family members, or patient identity
Looking for information on what immunization was given last, is currently due, or past due
Trying to find out if missed opportunities occurred within the patient's family (siblings, etc)
Researching medical topics such as indications and contraindications for vaccines
Preparing special reports for government immunization reporting purposes
• Have you ever thought that immunizations could take less time and cost less if  it was computerized

Yes No
• Do you worry about the security your medical information because you report manually on paper?

Yes No

Thank you for completing our ASCIInc marketing survey!