National Improvement Video Challenge Application Form

Contact Information
Primary Contact Name

Question Title

* 1. Primary Contact Name

Primary Contact Title

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* 2. Primary Contact Title

Primary Contact Email Address

Question Title

* 3. Primary Contact Email Address

Institution/Organization/Team Information (Optional)
Name of Institution/Organization/Team

Question Title

* 4. Name of Institution/Organization/Team

Video Information
Videos should be uploaded directly to YouTube or Vimeo by the submitting institution. Instructions on how to upload videos can be found here: YouTube | Vimeo.
Copy and paste the URL to your YouTube or Vimeo video.
Be sure it works or we won't be able to find your video!

Question Title

* 5. Copy and paste the URL to your YouTube or Vimeo video.
Be sure it works or we won't be able to find your video!

Authorization 
I am submitting a video entry for consideration in the Council on Patient Safety in Women's Health Care Video Challenge and have read the official rules. The submitted video is original work and does not include any copyrighted material used without written consent.

All participants have knowingly agreed to appear in my video and if applicable, have signed any release or authorization forms required by my organization/institution. 

I understand that by submitting this entry, the video becomes the property of the Council on Patient Safety in Women's Health Care.
Initials

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* 6. Initials

Date

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* 7. Date

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