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PQCNC Birth Certificate Pilot Roster Form

1. Our facility's name and address are below:
Space Cell Name of FacilityAddressCityStateZip
1
2. Our team contact information is below:
Space Cell Last NameFirst NameEmailPhoneTitle/Position
Hospital Executive Champion
Pilot Team Leader
Birth Registrar Lead
Clinical Lead
Nursing Director for Postpartum
Nurse Manager for Postpartum
Data Abstractor Lead
Pt/Family Team Member
Birth Registrar
Birth Registrar
Birth Registrar
IT contact at your facility that works with postpartum department
Other support person who assists with collection of birth certificate information
Team Member
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