Clinician Champions in Comprehensive Antibiotic Stewardship

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Please complete this form if interested in joining the Clinician Champions in Comprehensive Antibiotic Stewardship (CCCAS) Collaborative - A joint effort of Health Care Without Harm (HCWH), the Pediatric Infectious Disease Society (PIDS) and the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) group.
Members will be added to the Collaborative email list to receive updates on quarterly meetings, policy actions, and emerging research and developments in the field of antibiotic stewardship.

Name *

Credential *

Job Title *

Place of practice

Physicians Office

Hospital - Teaching

Hospital - non-teaching

Skilled Nursing Facility or CCRC

Hospice

Urgent care

Home healthcare

Reasearch

Other:

Professional organization affiliations (if applicable)

ex: American Medical Association, American Public Health Association Committee X, Peer Listserv names

Facility organization affiliations (if applicable)

ex: Acme Hospital, Acme Health Center

Location: City, State, Zipcode *

Email address *

Phone

What interests you about joining the CCCAS Collaborative?

Would you like to receive news and other emails about: *

CCCAS (If your application is accepted to join the collaborative, you will receive emails with updates, news, and action opportunities for the CCCAS collaborative.)

General interest in Health Care Without Harm

National Healthy Food in Health Care

California Healthy Food in Health Care (also includes national)

Mid-Atlantic Healthy Food in Health Care (also includes national)

New England Healthy Food in Health Care (also includes national)

Northwest Healthy Food in Health Care (also includes national)

Southwest Healthy Food in Health Care (also includes national)

Not at this time

Required

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