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PQIP Subcommittee Interest Form
Thank you for your interest in Perinatal Quality Improvement Panel (PQIP) subcommittee membership. Please complete the following and our team will follow up with next steps.
Please email any questions to
info@cpqcc.org
. Thank you.
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* Indicates required question
First and Last Name
*
Your answer
Email
*
Your answer
Job Title/Role
*
Neonatologist
Pediatrician/Pediatric Hospitalist
Neonatal Fellow
Medical Resident
Nurse Practitioner
Physician Assistant
Nurse
Clinical Nurse Specialist
Pharmacist
Infectious Disease Specialist
Other:
Required
Hospital Affiliation (or other affiliation)
*
Your answer
City, State
*
Your answer
Do you have volunteer experience with a non-profit?
*
Yes
No
If yes, please list which organizations and your role.
Your answer
Which subgroup are you interested in?
*
Education & Outreach Committee
QI Infrastructure Committee
Research Committee (PRC)
Data Interface and Opportunities Committee (DIOC)
Required
How did you hear about CPQCC?
Your answer
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