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* 1. Commitment statement: Our hospital administrative leadership (CEO,CNO or other officer) and our ICU Leadership (ICU Medical Director and Nursing Director/Manager) have read and understand the participation requirements listed on http://www.myicucare.org/Thrive/Healthcare-Provider/Pages/THRIVE-Peer-Support-Collaborative.aspx.  We understand that administrative   
sponsors must commit to supporting the staff during this quality improvement program with the resources necessary to be successful.

* 2. Please enter your name and credentials?

* 3. Are you a member of SCCM?

* 4. What is your e-mail address?

* 5. What is your phone number?

* 6. What is the name of your institution?

* 7. What is your institution address?

* 8. What type of hospital is your institution?

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

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

* 11. Describe the model you will use for running this a support group. For example, will the model consist of professionally-led       group visits with peer exchange; peer-led face-to-face self-management programs, or some other model?

* 12. Describe your plan to implement the group this year. (recruitement, advertising, location, etc.)

* 13. Will you and/or the team members be able to attend the full-day meeting at Congress in San Antonio on Tuesday February 27, 2018, at the 47th Critical Care Congress in San Antonio, Texas, USA?

* 14. Note: Our monthly calls occur on the second Thursday of each month at 3:00pm Central Time.  We anticipate having the new  sites join either the November 9th or the December 14th call.  Based on group consensus, we may set a new day and time for calls in 2018.

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