Information & Application Request Form

In order for us to best respond to your request, please complete and submit the following form. As soon as we receive your information, we will send you a complete program application. (Note: Fields marked with an asterisk [*] are required.)

CONTACT PERSON
*Salutation:
*First Name:
*Last Name:
*Title:
*Department:
*Institution:
*Address 1:
Address 2:
*City:
*State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY    *Zip Code:
*Phone:	Ext:
*Email:

Type Of Request

Check all that apply:

Information Packet | Teleconference | WebEx Web Meeting

INTEREST IN THE ACS NSQIP

Please rate your interest level in the program:

1 (low) | 2 | 3 | 4 | 5 (high)

Why are you interested in participating in the ACS NSQIP? (Check all that apply)
	For purposes of quality improvement
	For benchmarking my department's surgical outcomes against national outcomes
	To develop research
	I believe the ACS NSQIP is the best methodology for reporting risk-adjusted outcomes
	I do not want standards imposed on surgery by outside agencies
	I do not really want to participate, but I feel that I am compelled due to outside pressures

Is your hospital administration aware of the ACS NSQIP?

Yes | No | Don't Know

Comments

Please enter any comments or questions in the box below: