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* 1. Commitment statement: Our Hospital Administrative leadership (CEO or other and CNO) and our ICU Leadership (ICU Medical Director and Nursing Director/Manager) have read the call for proposal document and understand all of the requirements to participate in this support group network. We understand that administrative sponsors must commit to supporting the staff during this quality improvement program with the resources necessary to be successful.

* 2. What is your name and credentials?

* 3. Are you a member of SCCM?

* 4. What is your email address?

* 5. What is your phone number?

* 6. What is the name of your institution?

* 7. Institution address?

* 8. What is your hospital type?

* 9. Describe the institutional context and specific local leadership team who would organize and run the group. 

* 10. Does your hospital currently offer any type of support groups/services for patients after discharge?

* 11. Describe the model you will use for running such a group and the experience on which you will draw to support the group, if any.

* 12. Describe your plan to implement the group this year.

* 13. Describe how SCCM seed grant money will help you succeed.

* 14. Describe how participation in the Thrive Network will help you succeed.

* 15. Provide your budget and justification for the $5,000 seed grant money.

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