Electronic Health Record (EHR) Interview Questionnaire Form
Please complete this questionnaire to provide non-sensitive information about your EHR use case. This form is for interview intake purposes only and does not collect sensitive medical or financial data.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Organization Name
*
Organization Type
*
Please Select
Hospital
Clinic
Private Practice
Research Institution
Other
Your Role in the Organization
*
Please Select
IT/Systems Administrator
Clinician/Physician
Nurse
Administrative Staff
Other
Which EHR system is used?
*
Briefly describe the primary EHR use case for this interview
*
What are your main goals or objectives with the EHR system?
What challenges have you encountered with your EHR implementation?
Any additional comments or feedback?
Submit Questionnaire
Should be Empty: