Hypertension Initiative Enrollment and Information Request WisPQC/AIM Severe Maternal Hypertension Initiative Enrollment Thank you for your interest in the Severe Maternal Hypertension Initiative. To get involved, please choose one of the following:* I don't need any additional information, and I'm definitely going to ENROLL! I'm interested, and will definitely ENROLL. Keep me informed. I'm interested, but would like MORE INFORMATION. When would be a good time to contact you? Site IdentificationName of Site* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*This is to determine the WAPC Perinatal Region for the site. Contact InformationName* First Last Address (if different than site address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Title* Email (contact named above)* Phone*Is the site a hospital?* Yes No Hospital InformationHas the hospital completed the WAPC Levels of Care self-assessment survey for maternal services?* Yes No What level of maternal care does the hospital provide?* Level I Level II Level III Level IV Hospital Champion TeamNurse champion* First Last Email (nurse champion)* Pharmacist champion* First Last Email (pharmacist champion)* Physician champion* First Last Email (physician champion)* Emergency department champion (strongly recommended) First Last Email (emergency department champion) Primary data contact*This should be the person who is primarily responsible for data collection and/or submission. You may add additional names in the space below. First Last Email (data contact)* Other team members (e.g., social workers, therapists (occupational, physical, speech), nutritionists, etc.)Please use the space above to identify any others you think should be included on initiative communications. (During the initiative, you may add others by contacting staff.) PLEASE INCLUDE EMAIL ADDRESSES.Champion TeamChampion Team*Who will lead your efforts in quality improvement? Data Nurse Physician Social Worker Therapist Others Name of Data Champion First Last Email of Data Champion Name of Nurse Champion First Last Email of Nurse Champion Name of Physician Champion First Last Email of Physician Champion Name of Social Work Champion First Last Email of Social Work Champion Name of Therapist Champion First Last Email of Therapist Champion Other team membersPlease use the space above to identify any others you think should be included on initiative communications. PLEASE INCLUDE EMAIL ADDRESSES. (During the initiative, you may add others by contacting staff.) Contact Information SharingIn the spirit of collaboration, we would like to be able to facilitate communication between initiative participants. By checking "yes", we will include names and contact information for the individuals listed on this form. By checking "no", we will not share the information. If you check "restrictions", you will have the option to describe who can be listed.This information will be included in the password protected area of the initiative. Yes No Restrictions Please describe any restrictions.
