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First name*

Last name*

Job Title *

Company Name *

Country *

Address 1 *

Address 2

City/Town *

State/ Province *

Select...AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Minor Outlying IslandsUtahVermontVirgin Islands of the U.S.VirginiaWashingtonWest VirginiaWisconsinWyomingOthers

Zip code *

Phone Number *

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Business Email *

Which of the following best describes your primary job function?

Corporate Management IS/IT/Management Communications/Network management Engineering/Manufacturing management Software/Product Development Marketing/Sales Other (please specify)

How many people are employed in your entire organization including all branches, divisions, and subsidiaries? (Select one only) *

Total Employees in your entire organization 1. Over 40,000 2. 30,001 - 40,000 3. 20,001 - 30,000 4. 10,001 - 20,000 5. 5,001 - 10,000 6. 1,001 - 5,000 7. 501 - 1,000 8. 100-500 9. Less than 100

Which of the following best describes your organization's industry or function? (Select one only) *

Please select an industry..... 1. Manufacturing 2. Finance/Banking/Accounting 3. Insurance/Real Estate/Legal 4. Wholesaler/Retailer/Distributor 5. Government: Federal (including Military) 6. Government: State or Local (including Law Enforcement) 7. Transportation/Utilities (Energy, Water, etc.) 8. Education/Non-Profit 09. Healthcare/Medical Services/Pharmaceutical/Bio-Tech 10. Media (Publishing/Broadcast)/Advertising/PR 11. Business Services/Consultant 12. Aerospace/Defense Contractor 13. Mining/Oil/Gas 14. Agriculture/Forestry/Fisheries 15. Construction/Architecture/Engineering 16. Manufacturing - (Hardware/Software) 17. Wholesaler/Retailer/Distributor 18. Communication Carriers (Telecomm/Data Comm) 19. VAR/VAD/OEM/Systems or Network Integrator 20. Computer or Network Consultant/Data Processing Services 21. Service Provider (ISP/ASP/MSP/BSP/ESP/Web Hosting) 22. E-Commerce/Internet 23. other

If your industry is "Other" please specify:*

What is the total revenue of your organization? (Select one only) *

Total annual revenues of entire organization 1. Over $40 Billion 2. $30 Billion to $39.9 Billion 3. $15 Billion to $29.9 Billion 4. $10 Billion to $14.9 Billion 5. $5 Billion to $9.9 Billion 6. $1 to $4.9 Billion 7. $501 to $999 Million 8. $101 to $500 Million 9. $50 to $100 Million 10. Under $50 Million

Which of the following products, services and / or technologies do you currently or plan to approve, specify, recommend, purchase or influence the purchase of? (Check all that apply) *

• Clinical Data Repository
• Continuity of Care Record (CCR)
• Clinical Decision Support (CDS)
• Electronic Health Record (EHR)
• Electronic Prescribing(e-Rx)
• Patient Administrative System(PAS)

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