PQCNC Initiative Roster Form

Reminder:

Participating Collaborative Hospitals are expected to:

Identify an implementation team to include local and travel components, a physician champion, nurse champion, family member and administrative champion
Participate on webinars or other telecommunications media and share their challenges and successes to provide for joint learning and practice improvements
Attend face to face meetings

1. Our facility is participating in the following initiative (name of the initiative NOT your facility name):

2. Our facility's name and address are below:

Space Cell	Name of Facility	Address	City	State	Zip
1	Name of Facility	Address	City	State	Zip

3. Our team's contact information is below:

Space Cell	Last Name	First Name	Email	Phone	Title/Position
Hospital Executive Champion	Last Name	First Name	Email	Phone	Title/Position
Project Team Leader	Last Name	First Name	Email	Phone	Title/Position
Physician Champion	Last Name	First Name	Email	Phone	Title/Position
Nurse Manager Champion	Last Name	First Name	Email	Phone	Title/Position
Data Entry Contact	Last Name	First Name	Email	Phone	Title/Position
Pt/Family Team Member	Last Name	First Name	Email	Phone	Title/Position
Team Member	Last Name	First Name	Email	Phone	Title/Position
Team Member	Last Name	First Name	Email	Phone	Title/Position
Team Member	Last Name	First Name	Email	Phone	Title/Position
Team Member	Last Name	First Name	Email	Phone	Title/Position

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