您的浏览器中未启用 JavaScript,因此无法打开此文件。请启用 JavaScript,然后重新加载。
Health Equity Taskforce Interest Form
Thank you for your interest in the Health Equity Taskforce. Please complete the following and our team will follow up with next steps.
Please email any questions to
info@cpqcc.org
. Thank you.
登录 Google
即可保存进度。
了解详情
* 表示必填
First and Last Name
*
您的回答
Email
*
您的回答
Job Title/Role
*
Current or Former NICU Parent
Neonatologist
Pediatrician/Pediatric Hospitalist
Neonatal Fellow
Medical Resident
Nurse Practitioner
Physician Assistant
Nurse
Clinical Nurse Specialist
Pharmacist
Infectious Disease Specialist
其他:
必填
Hospital Affiliation (or other affiliation)
*
您的回答
Do you have volunteer experience with a non-profit?
*
Yes
No
If yes, please list which organizations and your role.
您的回答
Which subgroup are you interested in?
*
Between NICUs
Within NICUs
Transition to Home
I'm interested in any.
必填
How did you hear about CPQCC?
您的回答
提交
第 1 页(共 1 页)
清除表单内容
切勿通过 Google 表单提交密码。
此表单是在 CPQCC 内部创建的。
举报滥用行为
表单