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. Question Title Cost of managing the problem. Question Title 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 uploadDocument 1 DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Upload any supporting documents here:File limit is 16 MB per uploadDocument 1 Question Title Document 2 DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Document 2 Question Title Document 3 DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Document 3 Contact Details: 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? Yes No Question Title Email Address Submit