ImpactSIIS Site Enrollment

1. Each site is required to complete a Security Agreement.

Download: Security Agreement

Original of signed Security Agreement should be mailed to:

Ohio Department of Health
Immunization Program, IMPACTSIIS
246 North High Street P.O. Box 118
Columbus, OH 43266-0118

2. Please provide the following information:

Facility Name:

Doing Business As:

Address 1:

Address 2:

City:

State:

-- Please select a state -- ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA Foreign Country GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARIANA ISLANDS NORTHERN MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MICRONESIA FEDERATED STATES OF MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip Code:

County:

ADAMS ALLEN ASHLAND ASHTABULA ATHENS AUGLAIZE BELMONT BROWN BUTLER CARROLL CHAMPAIGN CLARK CLERMONT CLINTON COLUMBIANA COSHOCTON CRAWFORD CUYAHOGA DARKE DEFIANCE DELAWARE ERIE FAIRFIELD FAYETTE FRANKLIN FULTON GALLIA GEAUGA GREENE GUERNSEY HAMILTON HANCOCK HARDIN HARRISON HENRY HIGHLAND HOCKING HOLMES HURON JACKSON JEFFERSON KNOX LAKE LAWRENCE LICKING LOGAN LORAIN LUCAS MADISON MAHONING MARION MEDINA MEIGS MERCER MIAMI MONROE MONTGOMERY MORGAN MORROW MUSKINGUM NOBLE OTHER OTTAWA PAULDING PERRY PICKAWAY PIKE PORTAGE PREBLE PUTNAM RICHLAND ROSS SANDUSKY SCIOTO SENECA SHELBY STARK SUMMIT TRUMBULL TUSCARAWAS UNION UNKNOWN/OTHER VAN WERT VINTON WARREN WASHINGTON WAYNE WILLIAMS WOOD WYANDOT

Phone:

Organization Type:

Hospital Laboratory Medical Practice

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