Multi-institution NICU Health Equity Rounds (HER) Effort

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in being a part of this multi-institutional effort to create a neonatology-focused health equity conference toolkit. The goal is to create and/or provide resources, conference outlines, and evaluation tools that can be used by others to implement at their respective institutions.

Please provide your contact information below and indicate your desired level of engagement in this initiative.

Name *

Email address *

Title *

Attending MD/DO

Fellow MD/DO

Resident MD/DO

NP/PA

Parent/Family Member

Community Partner

Other:

Institution *

Are Health Equity Rounds implemented at your current institution? *

Yes

What are you hoping to gain from involvement in this project? *

Ideas/guidance for clinical implementation at my institution

Opportunities to generate and disseminate scholarly products related to HER

Other:

Desired level of engagement *

Very involved (I'm hoping to be a leader / author on this project)

Somewhat involved (I want to participate but can't commit full time)

Minimally involved (I just want to stay in the loop/up-to-date on the results of this project)

Other:

Any additional comments?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms