IWeb User Guide

Pandemic Provider Registration

Pandemic Influenza Vaccine Provider Network registration is only available for some states.

Providers can register for the Pandemic Influenza Vaccine Provider Network only after they have created an IWeb account. Therefore, non-enrolled providers need to request access to the application prior to registering to become a pandemic provider.

For non-enrolled providers, read the information on the page about the Pandemic Influenza Vaccine Provider Network, select one of the three available options, and click Submit. The options are:

• Yes, include this practice in the Pandemic Influenza Vaccine Provider Network. - This does not obligate the practice to provide vaccine, but will ensure we receive vaccine information directly if a pandemic is declared.
• No, this practice is not likely to administer vaccine during a pandemic influenza national emergency and does not need to receive vaccine information directly during a pandemic.
• Don't know, I am not the decision maker for my facility.

Providers can register for the Pandemic Influenza Vaccine Provider Network on the Provider Enrollment Application form page if the following Administration > Properties > Vaccine Management options are enabled in addition to the regular Provider Agreement options:

• Enable Pandemic Provider Agreement Features
• Allow Providers to fill out Pandemic Enrollment Forms
• Allow Providers to sign Pandemic Provider Agreement

To complete the Pandemic Provider registration process, click Orders/Transfers > Provider Agreement from the menu. On the Provider Agreement / Pandemic Agreement page, click Pandemic Enrollment Form toward the bottom of the page. The Online Pandemic Influenza Registration Request page opens with fields categorized in four sections:

• Online Pandemic Influenza Registration Request (top section)
• Primary Pandemic Point of Contact (PPOC)
• Additional Persons Set Up to Receive Pandemic Communications
• Persons to Receive Pandemic Communications

Enter the information (click Add to add additional people to receive communications, which are then listed in the last section on the page), then click Save and Add Shipment Info to go on to the next page. The fields in the four sections on the first page are as follows:

Online Pandemic Influenza Registration Request (top section)

Field	Description
Check here if the TennIIS APP is the healthcare provider who will be the lead decision maker regarding the ordering and administration of pandemic influenza vaccine	Select this option if the TennIIS applicant is the healthcare provider that will be the lead decision maker for ordering and administration of pandemic influenza vaccines.
First Name	Enter the healthcare provider's first name. This field is required.
Middle Name	Enter the healthcare provider's middle name.
Last Name	Enter the healthcare provider's last name. This field is required.
Title	Enter the healthcare provider's title. This field is required.
TN License Type	Enter the healthcare provider's Tennessee license type. This field is required.
License #	Enter the healthcare provider's license number. This field is required.
DOB	Enter the healthcare provider's birthdate. This field is required.
Email	Enter the healthcare provider's email address. This field is required.
Phone	Enter the healthcare provider's phone number. This field is required.
Extension	If applicable, enter the extension number for the phone number.
Fax	Enter the healthcare provider's fax number. This field is required.
Check here if fax is the same as practice fax	Select this option if the fax number entered above is the same fax number that the office uses.
Check here if the APP does not wish to receive email updates in the event of an influenza pandemic. (The pandemic point of contact will still receive email updates.)	Select this option to only send email updates to the pandemic point of contact person instead of the healthcare provider listed in this section.

Primary Pandemic Point of Contact (PPOC)

Field	Description
Check here if the TennIIS PPOC is the person who will receive all planning and ordering instructions by email and/or fax during an influenza pandemic (for Tennessee users only)	Select this option if the TennIIS primary pandemic point of contact is the person to receive planning and ordering instructions by email or fax during influenza pandemics.
First Name	Enter the pandemic point of contact's first name. This field is required.
Middle Name	Enter the pandemic point of contact's middle name.
Last Name	Enter the pandemic point of contact's last name. This field is required.
Title	Enter the pandemic point of contact's title. This field is required.
Email	Enter the pandemic point of contact's email address. This field is required.
Confirm Email	Re-enter the email address. This field is required.
Phone	Enter the pandemic point of contact's phone number. This field is required.
Extension	If applicable, enter the extension number for the phone number.
Fax	Enter the pandemic point of contact's fax number. This field is required.
Check here if fax is the same as practice fax	Select this option if the fax number entered above is the same fax number that the office uses.
Preferred Method of Communication	Select the preferred method of communication from the drop-down list: Email, Fax, or Phone

Additional Persons Set Up to Receive Pandemic Communications

Field	Description
First Name, Middle Name, Last Name	Add the additional person's first name (required), middle name, and last name (required) in the provided fields.
Email	Enter the person's email address. This field is required.
Confirm Email	Re-enter the email address. This field is required.
Phone	Enter the person's phone number. This field is required.
Extension	If applicable, enter the extension number for the phone number.
Add	Click Add to add the person to the Persons to Receive Pandemic Communications list in the last section on the page. Add as many extra people as necessary, clicking Add after each one.

Persons to Receive Pandemic Communications

The first part of this section lists the main people to receive communications, while the Additional Persons section lists the additional people added in the previous section. The available columns in section are as follows:

Column	Description
First Name	The first name for each extra person to receive pandemic communications.
Middle Name	The middle name for each extra person to receive pandemic communications.
Last name	The last name for each extra person to receive pandemic communications.
Phone	The person's phone number.
Email	The person's email address
Edit	Click the Edit icon for a person to edit their contact information.
Delete	Click the Delete icon to delete an additional person in the list.

Pandemic Influenza Vaccine Shipment Form

The next page to appear after clicking the Save and Add Shipment Info button (or, for State Approver users, the View Shipment Info button) is the Pandemic Influenza Vaccine Shipment Form page. There are five categories of fields to fill out on this page:

• Facility Shipping Information
• Shipping Contact
• Shipping Instructions
• Assessment and Planning Information
• Patient Profile

After entering the information and selecting the options, click Save & Submit (Save & Submit to TDH for Tennessee users) to submit the form. You can click Save & Complete Later to leave and return to the form later.

The fields and options in each section on this second page are as follows.

Facility Shipping Information

Field	Description
Check here if the facility shipping name and address are the same as the TennIIS practice name and address (for Tennessee users only)	Select this option if the facility shipping name and address are the same as the TennIIS practice name and address.
Facility Shipping Name	If the shipping address is different, enter the facility shipping name here. This field is required.
Facility Shipping Street Address	If the shipping address is different, enter the shipping street address here. This field is required.
BLDG/Box/Suite/Etc.	If there is a building number, box number, suite number, etc., enter it here.
City	If the shipping address is different, enter the city here. This field is required.
State	If the shipping address is different, enter the state here. This field is required.
County	If the shipping address is different, select a county from the drop-down list. This field is required.
Zip Code	If the shipping address is different, enter the zip code here. This field is required.
Please select the option that best describes this practice	Select the option that best describes the practice (this field is required): This is an independent practice that will be directly receiving the shipment of pandemic influenza vaccine This is a hospital-affiliated practice that will be directly receiving the shipment of pandemic influenza vaccine This is a hospital-affiliated practice that will NOT be directly receiving the shipment of pandemic influenza vaccine

Shipping Contact

Field	Description
Check here if the shipping contact is the same as the primary pandemic point of contact (PPOC)	Select this option if the shipping contact is the same as the primary pandemic point of contact (PPOC), in which case these fields do not need to be filled out.
First Name	Enter the shipping contact's first name. This field is required.
Middle Name	Enter the shipping contact's middle name.
Last Name	Enter the shipping contact's last name. This field is required.
Title	Enter the shipping contact's title. This field is required.
Email	Enter the shipping contact's email address. This field is required.
Confirm Email	Re-enter the email address. This field is required.
Phone	Enter the shipping contact's phone number. This field is required.
Extension	If applicable, enter the extension number for the phone number.
Fax	Enter the shipping contact's fax number. This field is required.

Shipping Instructions

In this section, select the days that the facility is able to receive shipments, then select from the drop-down lists the time range on those days. (For example, Mondays 9:00 AM - 4:00 PM)

Assessment and Planning Information

In this section, assuming the US can distribute enough pandemic influenza vaccine to vaccinate every US resident within 6 months after the start of the vaccine distribution and that this vaccine is accepted by the public, enter the amounts for these questions/requests:

• Estimate the total number of healthcare staff, including affiliated professionals, this practice intends to vaccinate during the course of this 6-month vaccination program
• Estimate the total number of patients or other persons this practice intends to vaccinate on a weekly basis during the course of this 6-month vaccination program
• Estimate the total number of patients or other persons this practice intends to vaccinate on a routine clinic day (exclude special vaccine clinic events) during the course of this 6-month vaccination program

Select the option that best answers this question: Will you offer pandemic influenza vaccine to the general public or will you only vaccinate current patients?

• Pandemic influenza vaccine will be offered to the general public as well as current patients
• Pandemic influenza vaccine will be offered to current patients only

Patient Profile

For the questions in this section, select the answer from the drop-down list or enter an amount, whichever the answer requires. The questions in this section are as follows:

1. Does this practice currently immunize children less than 3 years of age?
2. Would this practice immunize children less than 3 years of age with this pandemic influenza vaccine?
3. Estimate the total number of children less than 3 years of age this practice intends to immunize with this pandemic influenza vaccine
4. Does this practice currently immunize children 3 through 8 years of age?
5. Would this practice immunize children 3 through 8 years of age with this pandemic influenza vaccine?
6. Estimate the total number of children 3 through 8 years of age this practice intends to immunize with this pandemic influenza vaccine
7. Does this practice currently immunize children 9 through 17 years of age?
8. Would this practice immunize children 9 through 17 years of age with this pandemic influenza vaccine?
9. Estimate the total number of children 9 through 17 years of age this practice intends to immunize with this pandemic influenza vaccine
10. Does this practice currently immunize adults 18 through 64 years of age?
11. Would this practice immunize adults 18 through 64 years of age with this pandemic influenza vaccine?
12. Estimate the total number of adults 18 through 64 years of age this practice intends to immunize with this pandemic influenza vaccine
13. Does this practice currently immunize adults 65 years of age and older?
14. Would this practice immunize adults 65 years of age and older with this pandemic influenza vaccine?
15. Estimate the total number of adults 65 years of age and older this practice intends to immunize with this pandemic influenza vaccine
16. Does this practice currently immunize pregnant women?
17. Would this practice immunize pregnant women with this pandemic influenza vaccine?
18. Estimate the total number of pregnant women this practice intends to immunize with this pandemic influenza vaccine

After this section, State Approver users can click the Back to Search Forms button to return to the Pandemic Forms Search page (see Approve Pandemic Forms).

Related topics:

• Approve Pandemic Forms
• Pandemic Enrollment Report
• Vaccine Management Properties
• Accept the Confidentiality Agreement
  
• Select an Organization/Facility
• Select a VFC PIN
• Change/Reset Password
• Document Center
• Tennessee Provider Registration
• Log Out

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