MS Stroke Network
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1
. At what level do you wish for your hospital to participate in the Mississippi Stroke Network? (PLEASE SEE HOME PAGE AT www.mshealthcarealliance.org FOR HOSPITAL LEVEL CRITERIA)
At what level do you wish for your hospital to participate in the Mississippi Stroke Network? (PLEASE SEE HOME PAGE AT www.mshealthcarealliance.org FOR HOSPITAL LEVEL CRITERIA)
Level I
Level II
Level III
Level IV
We do not wish to participate
2
. Please complete the following:
Please complete the following:
Hospital Name:
Address of Hospital:
City/Town:
Zip:
3
. Contact information for the individual completing survey
Contact information for the individual completing survey
Name:
Position at Hospital:
Email Address:
Phone Number:
4
. Contact information for the Chief Executive Officer of your hospital:
Contact information for the Chief Executive Officer of your hospital:
Name
Email
Phone #
5
. Contact information for the President of your hospital's Board of Trustees
Contact information for the President of your hospital's Board of Trustees
Name
Email
Phone #
6
. Contact information for your hospital's Stroke Medical Director:
Contact information for your hospital's Stroke Medical Director:
Name
Email
Phone #
Specialty / Title
7
. Contact information for your hospital's Stroke Program Coordinator:
Contact information for your hospital's Stroke Program Coordinator:
Name
Email
Phone #
8
. Contact information for your hospital's Medical Director of Emergency Medicine:
Contact information for your hospital's Medical Director of Emergency Medicine:
Name
Email
Phone #
9
. Contact information for your hospital's Medical Director of Intensive Care:
Contact information for your hospital's Medical Director of Intensive Care:
Name
Email
Phone#
10
. Which of the following best describes your hospital's corporate status?
Which of the following best describes your hospital's corporate status?
For-Profit
Not-for-Profit
Government
11
. Which of the following best describes your hospital setting/market?
Which of the following best describes your hospital setting/market?
Urban
Suburban
Rural
12
. Which of the following best describes your hospital's teaching status?
Which of the following best describes your hospital's teaching status?
Academic Medical Center
Community - Teaching
Community - Non-teaching
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