MCH-MRN Sign-up Form

Question Title

* 1. Would you like to participate in the Maternal and Child Health Measurement Research Network?

Yes

Question Title

* 2. Please rate your level of interest in participating in the MCH-MRN

Low participation (receiving information only)

Medium participation (including a link/widget on website, occasional feedback)

High participation (Regularly engaging in dissemination and Technical Working Groups)

Low participation (receiving information only)

Medium participation (including a link/widget on website, occasional feedback)

High participation (Regularly engaging in dissemination and Technical Working Groups)

Question Title

* 3. Below are some possible topical measurement areas of focus for the MCH-MRN Technical Working Groups. Please indicate all groups in which would you be interested in participating.

	Yes	Maybe	No
Flourishing and Positive Health (including Holistic Health and Well-being)	Flourishing and Positive Health (including Holistic Health and Well-being) Yes	Flourishing and Positive Health (including Holistic Health and Well-being) Maybe	Flourishing and Positive Health (including Holistic Health and Well-being) No
Preventive Care	Preventive Care Yes	Preventive Care Maybe	Preventive Care No
Family Health	Family Health Yes	Family Health Maybe	Family Health No
ACEs and Associated Risk and Protective Factors	ACEs and Associated Risk and Protective Factors Yes	ACEs and Associated Risk and Protective Factors Maybe	ACEs and Associated Risk and Protective Factors No
Preconception	Preconception Yes	Preconception Maybe	Preconception No
Middle Childhood	Middle Childhood Yes	Middle Childhood Maybe	Middle Childhood No
Adolescent Health	Adolescent Health Yes	Adolescent Health Maybe	Adolescent Health No
Managing Transitions	Managing Transitions Yes	Managing Transitions Maybe	Managing Transitions No
Health Equity	Health Equity Yes	Health Equity Maybe	Health Equity No

Other (please specify)

Question Title

* 4. Below are some possible cross-cutting methodological areas of focus for the MCH-MRN Technical Working Groups. Please indicate all groups in which would you be interested in participating.

	Yes	Maybe	No
Local Area Estimation	Local Area Estimation Yes	Local Area Estimation Maybe	Local Area Estimation No
Measure Development	Measure Development Yes	Measure Development Maybe	Measure Development No
Data Linkages & Sharing Data Across MCH Programs	Data Linkages & Sharing Data Across MCH Programs Yes	Data Linkages & Sharing Data Across MCH Programs Maybe	Data Linkages & Sharing Data Across MCH Programs No
Common Measurement Scaling, Scoring, and Reporting	Common Measurement Scaling, Scoring, and Reporting Yes	Common Measurement Scaling, Scoring, and Reporting Maybe	Common Measurement Scaling, Scoring, and Reporting No
Measure Harmonization (Across Programs and Initiatives)	Measure Harmonization (Across Programs and Initiatives) Yes	Measure Harmonization (Across Programs and Initiatives) Maybe	Measure Harmonization (Across Programs and Initiatives) No
Supporting Use and Maintenance of Existing Measures	Supporting Use and Maintenance of Existing Measures Yes	Supporting Use and Maintenance of Existing Measures Maybe	Supporting Use and Maintenance of Existing Measures No
Assessing Positive Deviance and Health Potential	Assessing Positive Deviance and Health Potential Yes	Assessing Positive Deviance and Health Potential Maybe	Assessing Positive Deviance and Health Potential No
Integrating Family- and Child-Reported Information into EHRs	Integrating Family- and Child-Reported Information into EHRs Yes	Integrating Family- and Child-Reported Information into EHRs Maybe	Integrating Family- and Child-Reported Information into EHRs No
Use of Non-Traditional Data (e.g. Observational, Qualitative, Crowd-Sourced, Biomarker)	Use of Non-Traditional Data (e.g. Observational, Qualitative, Crowd-Sourced, Biomarker) Yes	Use of Non-Traditional Data (e.g. Observational, Qualitative, Crowd-Sourced, Biomarker) Maybe	Use of Non-Traditional Data (e.g. Observational, Qualitative, Crowd-Sourced, Biomarker) No

Other (please specify)

Question Title

* 5. Please let us know the best way to contact you about your participation in the MCH-MRN:

Name, Credentials

Position/Title

Organization

E-mail

Work phone

Alternate phone