ASHEW Practice Registration Survey

1.Practice name:

2.Practice location:

Please list the contact information for your core QI team. Core QI teams should include a primary care physician (physician champion/MOC local leader), a clinical support staff, and an additional team member such as front office staff, practice manager, or care coordinator. If your practice has already identified a family advisor, please include the name of this individual as well.

3.Team Member 1: Physician Champion/MOC local Leader

First name

Last name

Credentials

E-mail

Phone

4.Team member 2 - Clinical Support Staff:

First name

Last name

Credentials

E-mail

Phone

5.Team member 3 - front office, practice manager, care coordinator, etc. (Please note that this person will be responsible for data submission):

First name

Last name

Credentials

Role in practice

E-mail

Phone

6.Family Advisor

We have identified a family advisor

We are in the process of recruiting a family advisor

We are concerned about our ability to recruit a family advisor

7.Team member 4 – Family Advisor:

First name

Last name

Credentials/related experience (if any)

E-mail

Phone

8.Which of the following best describes your practice?

9.Which of the following best describes the setting of your practice?

Urban

Suburban

Rural

10.Please indicate the number of full time equivalent (FTE) employees in your practice that may participate in this project:

Family physician

Pediatrician

Other physician

Nurse practitioner

Physician assistant

Medical assistant

Nurse

Nursing assistant

Care coordinator

Social worker

Case manager

Office manager

Front office

Other

Approximately how many well child visits do you conduct each month for the following ages:

16.What type of EHR does your practice site use?

ASHEW Practice Registration

Addressing Social Health and Early Childhood Wellness (ASHEW)