Name/Title: (required) Email: (required) Organization: (required) Hospital, Ambulatory or Other: (required) Legacy Systems: (please provide information below for each legacy system) Name: Application/module: Type (inpatient, acute, ambulatory, HR, etc.): Database size: # of Documents and Date Range: Legacy System Environment (On-premise or vendor hosted) and Database Type: Legacy System still supported by Vendor (Y/N): Current and/or future EHR and date of conversion/cut over: 1. Legacy System Access a. Type of users: b. Number of users: c. Reasons for access: d. Frequency/volume of access: 2. Future Legacy Access Requirements a. Type of users: b. Number of users: c. Reasons for access: d. Frequency/volume of access: e. Data formats (documents, discrete, scanned images, etc.): f. What security management software is utilized and is automated import of audit detail desired? g. Desired legacy data (data elements and date range) to be imported into current EHR? h. Other application integration requirements? 3. Current Data Structure a. Existing data formats (documents, discrete, scanned images, etc.): 4. Legacy Contract Structure & Cost (per system) a. Annual or monthly: b. Annual maintenance, support and licensing cost (total or per system): c. If annual, date of contract renewal: 5. Goals and Expectations a. Specific date by which your organization would like to have the system(s) retired? b. Have you or your organization gone through an archival project (or similar) in the past? 6. How did you hear about Trinisys?