Institution: *
Library/Department:
Street Address: *
City: *
County: *
State: *	American Samoa Arizona Armed Forces Pacific California Federated States of Micronesia Guam Hawaii Marshall Islands Nevada Northern Mariana Islands Palau
Zip/Mail Code:*
Phone: *	() - Ext.
Home Page (OPTIONAL):

Name: *
Title: *
Phone: *	() - ext.
Fax:	() - ext.
Email: *

Name:
Title:
Phone:	() - ext.
Fax:	() - ext.
Email:

1. Is your library or information center regularly staffed? *

Yes No

2. Does your library or information center have access to the Internet? *

Yes No

3. Does your library or information center have a collection of health sciences materials (for example, books, journals, audiovisuals, electronic databases)? *

Yes No

4. Does your library or information center provide information services to health professionals or to the general public? *

Yes No

5. Do you want your library to participate in DOCLINE, the National Library of Medicine's automated interlibrary loan (ILL) request routing and referral system? (Note: You should have a collection of journals to lend to other libraries in order to participate in DOCLINE.)*

Yes No

6. Do you want your library or information center listed in MedlinePlus.gov as a consumer health library that provides service to local residents? (see www.nlm.nih.gov/medlineplus/libraries.html) *

Yes No

7. Please describe your services (Check All That Apply):

For Affiliated Users

For Unaffiliated Health Professionals

For Public

Provides

Charges

Provides

Charges

Provides

Charges

Internet Training

Mediated Searching

Onsite Collection Access

Online Search Training

Reference Services

8. Please provide any comments about your services (OPTIONAL):

First line (35 characters max.): *
Second line (35 characters max., OPTIONAL):
Third line (35 characters max., OPTIONAL):

Your Name: *
Email: *
Phone: *	() - ext.

Same as above (Directory address)

Name: *
Institution: *
Library/Department:
Street Address: *
City: *
County: *
State:*
Zip/Mail Code:*

1. Email:
2. Email:

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