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Clinical Practice Guideline Topic Nomination Form

Please complete all sections.

Question Title

Clinical Problem:

Current Situation:

Question Title

Prevalence of the clinical problem.

Question Title

Burden of illness imposed by the problem: individual mortality, morbidity, or functional impairment.

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Cost of managing the problem.

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Variability in practice: significant differences in utilization rates for prevention, diagnosis, or treatment options.

Potential Impact:

Question Title

Potential of a guideline or assessment to improve health outcomes: expected effect on health outcomes.

Question Title

Potential of guideline or assessment to reduce costs: expected effect on costs (to sponsoring organization, other relevant agencies, patients and families, and/or society in general).

Question Title

Upload any supporting documents here:
File limit is 16 MB per upload

Document 1

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

Document 2

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

Document 3

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Contact Details:

Clinical Practice Guideline Topic Nomination Form

Question Title

Clinical Problem:

Question Title

Prevalence of the clinical problem.

Question Title

Burden of illness imposed by the problem: individual mortality, morbidity, or functional impairment.

Question Title

Cost of managing the problem.

Question Title

Variability in practice: significant differences in utilization rates for prevention, diagnosis, or treatment options.

Question Title

Potential of a guideline or assessment to improve health outcomes: expected effect on health outcomes.

Question Title

Potential of guideline or assessment to reduce costs: expected effect on costs (to sponsoring organization, other relevant agencies, patients and families, and/or society in general).

Question Title

Upload any supporting documents here:
File limit is 16 MB per upload

Document 1

Question Title

Document 2

Question Title

Document 3

Question Title

First and Last Name

Question Title

What is your role or perspective?
(e.g. physician, patient, professional society, industry)

Question Title

If you are making a suggestion on behalf of an organization, please provide the name of the organization and your position.

Question Title

May we contact you if we have questions about your nomination?

Question Title

Email Address

Clinical Practice Guideline Topic Nomination Form

Question Title

Clinical Problem:

Question Title

Prevalence of the clinical problem.

Question Title

Burden of illness imposed by the problem: individual mortality, morbidity, or functional impairment.

Question Title

Cost of managing the problem.

Question Title

Variability in practice: significant differences in utilization rates for prevention, diagnosis, or treatment options.

Question Title

Potential of a guideline or assessment to improve health outcomes: expected effect on health outcomes.

Question Title

Potential of guideline or assessment to reduce costs: expected effect on costs (to sponsoring organization, other relevant agencies, patients and families, and/or society in general).

Question Title

Upload any supporting documents here:File limit is 16 MB per uploadDocument 1

Question Title

Document 2

Question Title

Document 3

Question Title

First and Last Name

Question Title

What is your role or perspective?(e.g. physician, patient, professional society, industry)

Question Title

If you are making a suggestion on behalf of an organization, please provide the name of the organization and your position.

Question Title

May we contact you if we have questions about your nomination?

Question Title

Email Address

Upload any supporting documents here:
File limit is 16 MB per upload

Document 1

What is your role or perspective?
(e.g. physician, patient, professional society, industry)