Syphilis Review Board: Involvement Interest Form

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With recent increases in Syphilis cases all around the state of Colorado, CDPHE has established a "Syphilis Review Board" to help identify missed opportunities, and share best practices with our State-wide community of providers and collaborators. All applications will be reviewed through our internal process. You will be notified if additional information is needed, or if you were selected to participate in the Review Board. Thank you for your interest!

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E-Mail-Adresse *

Name and Title *

Agency *

What is your role at your agency?

Please describe the population your agency primarily serves *

What is the zip code(s) in which you work?

Roughly, how many cases of syphilis per year does your agency see?

Please tell us why you are interested in serving on the Colorado Syphilis Review Board. What would you consider your area of expertise? *

How much time, in hours, can you commit to these efforts (monthly) *

1 hour

2 hours