HPH Exit Form
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Leaving the International HPH Network?

Please take a few moments to tell us why, so we can improve in the future.
Please indicate your reasons for terminating your HPH membership. If you wish, you can freely select only the fields that apply to your specific situation and your specific resignation.

1. Member Hospital / Health Service name:

Member Hospital / Health Service name:

2. Member Hospital / Health Service Coordinator:

Member Hospital / Health Service Coordinator:

3. National / Regional Network name (if applicable):

National / Regional Network name (if applicable):

4. Date of resignation:

Date of resignation:

5. Signature and date:

Signature and date:

6. Primary reason for leaving HPH is:

Primary reason for leaving HPH is:

7. HPH work in the organization has been:

HPH work in the organization has been:

8. The future of HPH in the organization is:

The future of HPH in the organization is:

9. To have keept us onboard, HPH should:

To have keept us onboard, HPH should:

10. Further comments:

Further comments:

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