PQCNC AIM clOUDi Roster Form

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

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

Please fill out the positions that you know, leaving blank those about which you are unsure, and submit to ensure that you begin receiving emails/newsletters/etc. and are kept up-to-date on the initiative. You may return as frequently as necessary to complete the roster for your team

2. Our team contact information is below:

Space Cell	Last Name	First Name	Email	Phone	Title/Position
Hospital Executive Champion	Hospital Executive Champion: Last Name	Hospital Executive Champion: First Name	Hospital Executive Champion: Email	Hospital Executive Champion: Phone	Hospital Executive Champion: Title/Position
Project Team Leader	Project Team Leader: Last Name	Project Team Leader: First Name	Project Team Leader: Email	Project Team Leader: Phone	Project Team Leader: Title/Position
Physician Champion - Maternal	Physician Champion - Maternal: Last Name	Physician Champion - Maternal: First Name	Physician Champion - Maternal: Email	Physician Champion - Maternal: Phone	Physician Champion - Maternal: Title/Position
Physician Champion - Newborn	Physician Champion - Newborn: Last Name	Physician Champion - Newborn: First Name	Physician Champion - Newborn: Email	Physician Champion - Newborn: Phone	Physician Champion - Newborn: Title/Position
Nurse Manager Champion - Maternal	Nurse Manager Champion - Maternal: Last Name	Nurse Manager Champion - Maternal: First Name	Nurse Manager Champion - Maternal: Email	Nurse Manager Champion - Maternal: Phone	Nurse Manager Champion - Maternal: Title/Position
Nurse Manager Champion - Newborn	Nurse Manager Champion - Newborn: Last Name	Nurse Manager Champion - Newborn: First Name	Nurse Manager Champion - Newborn: Email	Nurse Manager Champion - Newborn: Phone	Nurse Manager Champion - Newborn: Title/Position
Social Work Contact	Social Work Contact: Last Name	Social Work Contact: First Name	Social Work Contact: Email	Social Work Contact: Phone	Social Work Contact: Title/Position
Pharmacy Contact	Pharmacy Contact: Last Name	Pharmacy Contact: First Name	Pharmacy Contact: Email	Pharmacy Contact: Phone	Pharmacy Contact: Title/Position
Data Entry Contact	Data Entry Contact: Last Name	Data Entry Contact: First Name	Data Entry Contact: Email	Data Entry Contact: Phone	Data Entry Contact: Title/Position
IT Support	IT Support: Last Name	IT Support: First Name	IT Support: Email	IT Support: Phone	IT Support: Title/Position
Pt/Family Team Member	Pt/Family Team Member: Last Name	Pt/Family Team Member: First Name	Pt/Family Team Member: Email	Pt/Family Team Member: Phone	Pt/Family Team Member: Title/Position
Pt/Family Team Liasion (staff member who will work closest with pt/family member)	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Last Name	Pt/Family Team Liasion (staff member who will work closest with pt/family member): First Name	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Email	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Phone	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position

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PQCNC AIM clOUDi Roster Form

PQCNC AIM clOUDi Roster Form