What is the name of your organization?

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* 1. What is the name of your organization?

Please tell us the contact information for the point person for this project at your organization:

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* 2. Please tell us the contact information for the point person for this project at your organization:

Please tell us your contact information:

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* 3. Please tell us your contact information:

Please list the names and phone numbers for the other members of your team who will be attending

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* 4. Please list the names and phone numbers for the other members of your team who will be attending

Which of the following topics are of most interest to you (select as many as you like)

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* 5. Which of the following topics are of most interest to you (select as many as you like)

Please tell us any other topics that you want to know about in pediatric palliative care.

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* 6. Please tell us any other topics that you want to know about in pediatric palliative care.

In the past year, how many pediatric patients have you personally provided palliative care to?

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* 7. In the past year, how many pediatric patients have you personally provided palliative care to?

What percentage of patients in your practice need pediatric palliative care?

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* 8. What percentage of patients in your practice need pediatric palliative care?

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