I-QIPS Email Sign-Up Form

This form should be completed by those who wish to sign-up to receive emails from the Institute for Continuing Professional Development in Quality Improvement and Patient Safety (I-QIPS) at Baylor College of Medicine (BCM) regarding I-QIPS news and announcements, including upcoming QI training courses and faculty development opportunities.

You may update your email address or unsubscribe at any time. For questions, please contact: I-QIPS Team

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* 1. Prefix

Dr.

Mr.

Ms.

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* 2. First Name

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* 3. Last Name

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* 4. Email Address

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* 5. Professional Category (select all that apply)

MD / DO (in practice)

MD / DO: Fellow

MD / DO: Resident

PA, PA-C

PharmD

RN, LVN

PhD / PsyD / EdD / DrPH

MBA / MHA / MPH

Other - Professional Category (please specify)

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* 6. Your Primary Institution

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* 7. Your Department (at primary institution)

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* 8. Reason for Email Subscription (select all that apply)

I am signing up to receive I-QIPS emails for my personal interest.

I am signing up to receive I-QIPS emails on behalf of my supervisor.

Other - Reason for Subscription (please specify)

EMAIL CONSENT
By submitting this form, I am acknowledging BOTH of the following:

1. I confirm my consent to receive emails from the Institute for Continuing Professional Development in Quality Improvement and Patient Safety (I-QIPS) at Baylor College of Medicine (BCM) regarding general I-QIPS news and updates, including announcements about other QI/PS-related activities offered by BCM and affiliated institutions.

2. I confirm that understand that I may update my email address and/or unsubscribe at any time.