JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Code True – Founding Member Application
Apply to join as a Founding Member. Help us bring resilience to ER and ICU teams and create lasting culture change in your hospital.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full Name
*
Your answer
Position / Title
*
Your answer
Organization / Hospital Name
*
Your answer
Department or Unit (if applicable)
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Decision-Maker Alignment
*
I am the final decision-maker
Others should be included
Other:
How does your organization currently support ER/ICU staff in managing stress and preventing burnout?
*
Your answer
Does your organization have Leadership Commitment?
Yes
No
In Progress
Other:
Clear selection
Strategic Priority
*
Lowering turnover
Reducing agency spend
Improving safety
Strengthening staff morale
Required
Capacity for Partnership
Yes, we are ready now
Yes, within the next 3–6 months
Not yet
Clear selection
How does your organization see a culture of resilience fitting into your Magnet, retention, or patient safety goals over the next 12 months?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report