ASIIS Enrollment Application
(View Privilege Only)
DIRECTIONS: Please complete and submit this form to AS
IISHelpDesk@azdhs.gov
.
Zip: County________________
FAX #: ( )
Organization and/or District:
Physical Address:
City:
Phone #: ( )
Main Contact:
E-mail address:
Mailing Address:
City:
Zip: County_______________
Please list the full name and email for each staff members who will use the web application.
ASIIS is a computer based immuniz
ation registry a
nd tracki
ng
system
implemented by the Arizona Department of Health Services and its
partners. It is intended to aid health care professionals and other users who have a need to check a client’s immunization status
according to A.R.S § 36-135, R9-6-707, and R9-6-708. Through ASIIS, providers can place orders for publicly funded vaccines to provide to
children eligible to receive VFC vaccines. Client-specific information and vaccine ordering privileges are only available to authorized users
and the Arizona Department of Health Services. The Users enters into this agreement with the Arizona Department of Health Services
and agree to adhere to all requirements that are listed in the Pledge to Protect Confidential Information.
Please contact ASIISHelpDesk@azdhs.gov if you have any questions.
All Users shall electronically accept the terms of the Pledge to Protect Confidential Information on their first login.
Public School
Charter School
Private School
School District
Daycare/Childcare
DES/DCS
Other (please specify)
Type of Organization:
(Select only one)
IRMS:
Last Revision: June 2016
State: ____
State: ____
Name E-mail Address
