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Thank you for your interest in the Mental Health QI Learning Collaborative. The application for participation should only take 5-10 minutes to complete.

Before you begin, please note that you will need email addresses for all practice based participants.

If you have any questions, please do not hesitate to contact the project coordinator Tamara John at tjohn@childrensnational.org

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* 1. Communications and materials for this collaborative will come via the internet and email. You will need to have access to both internet and email to participate in this collaborative. Does your practice have access both to internet and email?

Practice Demographics

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* 2. Practice Name?

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* 3. Practice mailing address?

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* 4. If you are a DC based practice, in what Ward is your practice located?

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* 5. What percentage of your pediatric patients are from DC?

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* 6. What percentage of your pediatric patients are insured through Medicaid

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* 9. Does your practice or center use electronic health records?

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* 10. If yes, which one?

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* 11. Have you or anyone in your practice participated in a structured improvement project?

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* 12. If yes, have you participated in a CNHN Learning Collaborative?

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* 13. If yes, which one?

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* 14. Is your practice or center currently involved in any major activities or research studies that may presenta barrier to your participation in the learning collaborative?

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* 15. If yes, please elaborate on the research/activities:

Practice Information

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* 16. Project Team Leader contact information (The Team Leader will be the primary contact for the practice team and will lead all project related activities):

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* 17. Secondary Project Team Leader (Optional):

Participants in the Mental Health Learning Collaborative will have access to our quality improvement website-QI TeamSpace (QITS). QITS houses important forms, webinars, data reports and articles that all participants will need to access in order to earn MOC and CME credit.
Practice Team demographics:

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* 18. Team Member #1:

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* 19. Team Member #2:

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* 20. Team Member #3:

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* 21. Team Member #4:

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* 22. Team Member #5:

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* 23. Team Member #6:

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* 24. Team Member #7:

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* 25. Team Member #8:

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* 26. Team Member #9:

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* 27. Team Member #10:

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* 28. Team Member 11:

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* 29. Team Member #12:

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* 30. Team Member #13:

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* 31. Team Member #14:

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* 32. Team Member #15:

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* 33. Team Member #16:

Thank you for your interest in joining the 2014 9-month Mental Health QI Learning Collaborative. Once your application has been reviewed, Tamara John will contact you with further instructions regarding your participation and login information for QITS. If you have any questions, please feel free to email Ms. John at tjohn@cnmc.org.

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