Application for Access to the Dorenfest Institute for H.I.T. Research and Education Database Applicant

First Name: *
Last Name: *
Title (if any):

Organization:(university or government agency): *


Address: *


City: *  
State: *  
Zip Code: *  

Phone: *


E-mail address: *

Which name best describes your role at your organization or agency (choose one)? *

If you are a student, what is your course of study (e.g., Masters in Public Health)?
Please describe the project for which you will be using this database. Describe the general topic, distribution of, and goal of the project. *
What is the end product of this project (choose one)? *


Do you plan to submit the end product for possible publication in a journal, magazine or book?

If yes, what is the publication you will be submitting to?


Please the names of all individuals within your organization who will be working with you on this project and with whom you may be sharing access to this database.
Are you a HIMSS member?
If your answer is ‘No,’ would you like to receive information on becoming a HIMSS member?
Would you like to receive information on the HIMSS Foundation Scholarship program?
Please carefully read the following Database Usage Agreement. If you understand and agree to the requirements of this agreement, please click ‘Yes’ for the boxes below.

Click to Read Usage Agreement  
* Required information.