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* 1. Name of Practice Facilitation program:

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* 2. Year of PF program start-up

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* 3. Name of PF program director:

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* 4. PF Program website:

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* 5. Administrative home for the PF program:

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* 6. Types of practices served (rural, urban, small, large, FQHC, primary care, specialty, etc):

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* 7. What are the primary goals of your PF intervention:

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* 8. What are the desired outcomes of your PF program?

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* 9. What activities do your PFs engage in when they work with a practice (data collection, training, set up EHR, workflow mapping, etc)?

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* 10. Number of FTE Practice Facilitators in your program:

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* 11. Number of practices served by your program in the past 24 months:

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* 12. How many practices does one PF support at a time?

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* 13. What is the primary modality (on-site, teleconference, web conference) used by your PFs when they work with a practice?

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* 14. How long does a typical PF intervention last:

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* 15. What is the schedule of your PF visits (daily, weekly, monthly, etc)?

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* 16. Where does the funding for your program come from?

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