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5 Which BEST describes your type of facility? (check one)

2 Check one: New Subscription Change of Address Renewal

Name ___________________________________________________________________________ Title _______________________________________________M.S./Dept.# ___________________ Company ____________________________________________________ Bldg.# ______________ Address _________________________________________________________________________ City ___________________________________________State _________ Zip ________________ Business Phone (_____) _____________________ Fax (_____) ___________________________

1 Hospital/Multi-Hospital System, IDN/Health Network 3 University/Teaching Hospital 4 Military/Government Hospital 7 Medical Clinic/Ambulatory Care Center 5 Group Practice 6 Physician Organization (IPA, PHO) 8 Long Term/Sub Acute Care/Nursing Home/Rehab 9 Home Health Care Agency

10 Managed Care Organization (HMO, PPO, Healthplans) 12 Third-Party Admin/Self Insured Employer 13 Pharmacy/Independent Lab 18 Imaging Center 14 IT Consultant/Project Management/Integration 17 Other _________________________________________

6 Which products/services do you buy, recommend or approve? (check ALL that apply)

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Hardware 50 Disaster Recovery/Preparedness 51 Mobile Workstations/POC 52 Monitors/Displays 53 Printers/Copiers/Scanners 54 Tablets/PDAs/Handhelds/Laptops Services/Smart Phones

4 Which BEST describes your job title/function? (check one)

Information Management 11 CIO/CMI/CTO/VP of Information Systems 5 CSO/VP/Director, Security

14 Director/Manager, Information Systems 15 Director/Manager, Medical Informatics 13 Director/Manager, Medical Records 12 Director/Manager, Network/Internet/Intranet/Wireless/E Health/Telecom 18 IT Consultant/IT Systems Analyst, Project Manager

Executive, Administrative & Financial Management 1 CEO/President/Administrator/Chairman of Board or Healthcare Committee 2 COO/VP of Operations 3 CFO/VP of Finance/Controller/Treasurer

27 Practice Administrator/Practice Manager 28 VP/Director/Manager, Managed Care 16 VP/Director/Administrator, Claims/Coding/Admissions/Patient Services

Clinical Management 20 Chief of Staff/CMO/Medical Director 25 Chief Nursing Offi cer/Director of Nursing/Case Manager 24 Chief of Radiology/Imaging, Radiologist/PACS-RIS Administrator 29 Chief of Cardiology/Oncology 23 Chief/Director Pharmacy, Pharmacist 21 Chief/Director Laboratory Services, Lab Director/Manager 30 Other healthcare title __________________________________________

Services 60 ASP/Internet/Intranet Services 61 Call Centers/Telecom 62 Collections 63 Enrollment, Benefi ts Management Software

Software 70 Bar Coding/RFID/Tracking Systems 71 Claims, Coding Processing 72 Clinical Information Systems 73 Data Storage/Mining 74 Decision Support (Clinical, Financial) 75 Document Management/Imaging 77 EMR/EHR 78 EDIS/Perioperative Systems 79 Financial Billing Systems 80 Hospital/Healthcare Info Systems 81 Managed Care Systems 83 Medication Management/Drug Info Systems 84 Physician Practice Management 85 Radiology/PACS/RIS/Diagnostic Imaging 86 Scheduling Systems 87 Security/Authentication/Biometrics 88 Speech Recognition/Transcription 89 Wireless Applications 90 Workfl ow Automation 93 Revenue Cycle Management 94 Mobile Device Applications

900 None of the above

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