VFC Provider Enrollment

Field Name	Description
Facility Name	Required. Free-text field with default value of practice name on record within registry. Minimum length is 1; maximum length is 100.
Street Address	Required. Free-text field with default value of practice address on record within registry. Minimum length is 1; maximum length is 40.
City	Required. Free-text field with default value of city on record within registry. Minimum length is 1; maximum length is 30.
State	Required. A drop-down list containing all states. Default value of state on record within registry.
Zip Code	Required. 5 digits. Default value of zip code on record within registry.
Zip+4	4 digits. Default value of zip+4 on record within registry, if present.
County	Required. A drop-down list containing all Wisconsin counties with a default value of the county on record within registry, if present.
Phone	Required. Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits. Default value of Facility Telephone on record within registry.
Fax	Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits. Default value of fax number on record within registry, if present.
Medical Director (Last)	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
First	Required. Free-text field with no default value. Minimum length is 1; maximum length is 25.
M.I.	Free-text field with no default value. Maximum length is 1.
Medical License Number	Required. Minimum length is 3; maximum length is 20.
NPI	Required (if no Medicaid Number). Free-text field with no default value. Minimum length is 10; maximum length is 10.
Medicaid Number	Required (if no NPI). Free-text field with no default value. Minimum length is 8; maximum length is 8.
Title	Required. A drop-down list containing titles including but not limited to DO, MD, ND, NP, PA, Other.
Specialty	Required. A drop-down list containing specialties including but not limited to GP, Med, Peds.
Primary Vaccine Coordinator (Last)	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
First	Required. Free-text field with no default value. Minimum length is 1; maximum length is 25.
Telephone	Required. Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits.
Email	Required. Free-text field with no default value. Minimum length is 1; maximum length is 50.
Contact Type	Required. A drop-down list with no default value used to indicate whether coordinator is a physician or non-physician contact.
Completed Annual Training	Required. Radio button selection indicating whether coordinator has completed annual training requirements.
Type of Training Received	Required (if Completed Annual Training = Yes). Pick-list containing the annual training types.
Backup Vaccine Coordinator (Last)	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
First	Required. Free-text field with no default value. Minimum length is 1; maximum length is 25.
Telephone	Required. Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits.
Email	Required. Free-text field with no default value. Minimum length is 1; maximum length is 50.
Contact Type	Required. A drop-down list with no default value used to indicate whether coordinator is a physician or non-physician contact.
Completed Annual Training	Required. Radio buttons to indicate whether coordinator has completed annual training requirements.
Type of Training Received	Required (if Completed Annual Training = Yes). A drop-down list used to indicate which training type was completed by the coordinator.
Facility Type	Required: Choose one of the Facility Types listed.
Private Facilities	If the facility is a private facility, select the applicable option from the list.
Private Hospital	Required. Select this option to indicate the facility is a Private Hospital.
Private Practice (solo/group/HMO)	Required. Select this option to indicate the facility is a Private Practice.
Private Practice (solo/group as agent for FQHC/RHC-deputized)	Required. Select this option to indicate the facility is a Private Practice deputized as a Federally Qualified Health Center or Rural Health Clinic.
Community Health Center	Required. Select this option to indicate the facility is a private Community Health Center.
Pharmacy	Required. Select this option to indicate the facility is a Pharmacy.
Birthing Hospital	Required. Select this option to indicate the facility is a Birthing Hospital.
School-Based Clinic	Required. Select this option to indicate the facility is a private School-Based Clinic.
Teen Health Center	Required. Select this option to indicate the facility is a private Teen Health Center.
Adolescent Only Provider	Required. Select this option to indicate the facility is a private Adolescent Only Provider.
Other:	Required. Select this option to indicate the facility is another type of private facility. Fill out the description field that appears below the Type of Facility section.
Public Facilities	If the facility is a public facility, select the applicable option from the list.
Public Health Department Clinic	Required. Select this option to indicate the facility is a Public Health Department.
Public Health Department Clinic as agent for FQHC/RHC-deputized	Required. Select this option to indicate the facility is a Public Health Department deputized as a Federally Qualified Health Clinic or Rural Health Clinic.
Public Hospital	Required. Select this option to indicate the facility is a Public Hospital.
FQHC/RHC (Community/Migrant/Rural)	Required. Select this option to indicate the facility is a Federally Qualified Health Clinic or Rural Health Clinic.
Community Health Services Clinic	Required. Select this option to indicate the facility is a public Community Health Services Clinic.
Tribal/Indian Health Services Clinic	Required. Select this option to indicate the facility is a Tribal/Indian Health Services Clinic.
Women, Infants and Children	Required. Select this option to indicate the facility is a WIC clinic.
STD/HIV	Required. Select this option to indicate the facility is a STD/HIV clinic.
Family Planning	Required. Select this option to indicate the facility is a Family Planning Clinic.
Juvenile Detention Center	Required. Select this option to indicate the facility is a Juvenile Detention Center.
Correctional Facility	Required. Select this option to indicate the facility is a Correctional Facility.
Drug Treatment Facility	Required. Select this option to indicate the facility is a Drug Treatment Facility.
Migrant Health Facility	Required. Select this option to indicate the facility is a Migrant Health Facility.
Refugee Health Facility	Required. Select this option to indicate the facility is a Refugee Health Facility.
School-Based Clinic	Required. Select this option to indicate the facility is a public School-Based Clinic.
Teen Health Center	Required. Select this option to indicate the facility is a public Teen Health Center
Adolescent Only Provider	Required. Select this option to indicate the facility is a public Adolescent Only Provider.
Other:	Required. Select this option to indicate the facility is another type of public facility. Fill out the description field that appears below the Type of Facility Section.
Vaccines Offered	Required: Choose the option that reflects which vaccines are offered by the facility.
All ACIP Recommended Vaccines	Required. Select this option to indicate the facility offers all vaccines recommended by ACIP.
Offers Select Vaccines	Required. Select this option to indicate the facility is a speciality provider offering only select vaccines. Select the applicable check boxes corresponding to the vaccines offered by this facility.
	Pressing Continue will save information and take you to screen two of the enrollment process.
	Pressing Cancel will take you to the Registration and Renewal page. No entries will be saved.

Field Name	Description
Facility Name	Required. Free-text field with no default value. Minimum length is 1; maximum length is 100.
Street Address	Required. Free-text field with no default value. Minimum length is 1; maximum length is 40.
City	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
State	Required. A drop-down list containing all states.
Zip Code	Required. 5 digits.
Zip+4	4 digits.
County	Required. A drop-down list containing all Wisconsin counties.
Phone	Required. Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits.
Fax	Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits.
Medical Director (Last)	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
First	Required. Free-text field with no default value. Minimum length is 1; maximum length is 25.
M.I.	Free-text field with no default value. Maximum length is 1.
Medical License Number	Required. Minimum length is 3; maximum length is 20.
NPI	Required (if no Medicaid Number). Free-text field with no default value. Minimum length is 10; maximum length is 10.
Medicaid Number	Required (if no NPI). Free-text field with no default value. Minimum length is 8; maximum length is 8.
Title	Required. A drop-down list containing titles including but not limited to DO, MD, ND, NP, PA, Other.
Specialty	Required. A drop-down list containing specialties including but not limited to GP, Med, Peds.
Primary Vaccine Coordinator (Last)	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
First	Required. Free-text field with no default value. Minimum length is 1; maximum length is 25.
Telephone	Required. Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits.
Email	Required. Free-text field with no default value. Minimum length is 1; maximum length is 50.
Contact Type	Required. A drop-down list used to indicate whether coordinator is a physician or non-physician contact.
Completed Annual Training	Required. Radio button selection indicating whether coordinator has completed annual training requirements.
Type of Training Received	Required (if Completed Annual Training = Yes). A drop-down list used to indicate which training type was completed by the coordinator.
Backup Vaccine Coordinator (Last)	Required. Free-text field with no default value. Minimum length is 1; maximum length is 30.
First	Required. Free-text field with no default value. Minimum length is 1; maximum length is 25.
Telephone	Required. Area Code: 3 digits. Prefix: 3 digits. Suffix: 4 digits. Extension: 10 digits.
Email	Required. Free-text field with no default value. Minimum length is 1; maximum length is 50.
Contact Type	Required. A drop-down list used to indicate whether coordinator is a physician or non-physician contact.
Completed Annual Training	Required. Radio buttons to indicate whether coordinator has completed annual training requirements.
Type of Training Received	Required (if Completed Annual Training = Yes). Pick-list containing the annual training types.
Facility Type	Required: Choose one of the Facility Types listed.
Private Facilities	If the facility is a private facility, select the applicable option from the list.
Private Hospital	Required. Select this option to indicate the facility is a Private Hospital.
Private Practice (solo/group/HMO)	Required. Select this option to indicate the facility is a Private Practice.
Private Practice (solo/group as agent for FQHC/RHC-deputized)	Required. Select this option to indicate the facility is a Private Practice deputized as a Federally Qualified Health Center or Rural Health Clinic.
Community Health Center	Required. Select this option to indicate the facility is a private Community Health Center.
Pharmacy	Required. Select this option to indicate the facility is a Pharmacy.
Birthing Hospital	Required. Select this option to indicate the facility is a Birthing Hospital.
School-Based Clinic	Required. Select this option to indicate the facility is a private School-Based Clinic.
Teen Health Center	Required. Select this option to indicate the facility is a private Teen Health Center.
Adolescent Only Provider	Required. Select this option to indicate the facility is a private Adolescent Only Provider.
Other:	Required. Select this option to indicate the facility is another type of private facility. Fill out the description field that appears below the Type of Facility section.
Public Facilities	If the facility is a public facility, select the applicable option from the list.
Public Health Department Clinic	Required. Select this option to indicate the facility is a Public Health Department.
Public Health Department Clinic as agent for FQHC/RHC-deputized	Required. Select this option to indicate the facility is a Public Health Department deputized as a Federally Qualified Health Clinic or Rural Health Clinic.
Public Hospital	Required. Select this option to indicate the facility is a Public Hospital.
FQHC/RHC (Community/Migrant/Rural)	Required. Select this option to indicate the facility is a Federally Qualified Health Clinic or Rural Health Clinic.
Community Health Services Clinic	Required. Select this option to indicate the facility is a public Community Health Services Clinic.
Tribal/Indian Health Services Clinic	Required. Select this option to indicate the facility is a Tribal/Indian Health Services Clinic.
Women, Infants and Children	Required. Select this option to indicate the facility is a WIC clinic.
STD/HIV	Required. Select this option to indicate the facility is a STD/HIV clinic.
Family Planning	Required. Select this option to indicate the facility is a Family Planning Clinic.
Juvenile Detention Center	Required. Select this option to indicate the facility is a Juvenile Detention Center.
Correctional Facility	Required. Select this option to indicate the facility is a Correctional Facility.
Drug Treatment Facility	Required. Select this option to indicate the facility is a Drug Treatment Facility.
Migrant Health Facility	Required. Select this option to indicate the facility is a Migrant Health Facility.
Refugee Health Facility	Required. Select this option to indicate the facility is a Refugee Health Facility.
School-Based Clinic	Required. Select this option to indicate the facility is a public School-Based Clinic.
Teen Health Center	Required. Select this option to indicate the facility is a public Teen Health Center
Adolescent Only Provider	Required. Select this option to indicate the facility is a public Adolescent Only Provider.
Other:	Required. Select this option to indicate the facility is another type of public facility. Fill out the description field that appears below the Type of Facility Section.
Vaccines Offered	Required: Choose the option that reflects which vaccines are offered by the facility.
All ACIP Recommended Vaccines	Required. Select this option to indicate the facility offers all vaccines recommended by ACIP.
Offers Select Vaccines	Required. Select this option to indicate the facility is a speciality provider offering only select vaccines. Select the applicable check boxes corresponding to the vaccines offered by this facility.
	Pressing Continue will take you to screen two of the enrollment process.
	Pressing Cancel will take you to the Registration and Renewal page. Enrollment will be discarded.