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2004 National Collaborative Application Form

We would be happy to discuss tailoring our offerings to your needs and what we can help you achieve. For more information call Ekta Chaudhry at 202-895-2634, or email echaudhry@thewashingtonhome.org.

Fax to: (202) 966-5410
Mail to: Center For Palliative Care Studies
4200 Wisconsin Avenue, NW
Washington, DC 20016
Tel. (202) 895-2625

You may print this application form. Please complete it and return it to us via fax or surface mail.Please print or type:

Organization:

___________________________________________________

Contact Name:

___________________________________________________

Title:

___________________________________________________

Address:

___________________________________________________

City:

___________________________________________________

State/Province:

___________________________________________________

ZIP/Postal Code:

___________________________________________________

Phone:

___________________________________________________

Fax:

___________________________________________________

Email:

___________________________________________________


We wish to participate in the Third National Medicaring Quality Improvement Collaborative (MedQuIC) Organized by CPCS.

Signature:

___________________________________________________

Title:

___________________________________________________

(CEO, COO, VP for Medical Affairs, or equivalent must sign)

On a separate sheet:

  1. Briefly describe your organization (including organization type, size, and structure) and its current programmatic and quality improvement activities aimed at improving care for serious chronic illness.

  2. What does your organization want to accomplish as a participant in this collaborative? Describe in a paragraph your proposed area of focus. Please include any data describing your current performance in this area (confidentiality will be maintained).

  3. Please list the names and titles of the three people most likely to participate in the collaborative and attend the three Learning Sessions.