Applicant & Hospital Information

Thank you for applying to the Project BOOST Mentoring Program. The survey is divided into three sections and should take approximately 45-60 minutes to complete.

Applications are reviewed on a rolling basis and a letter of support from a senior administrator at your institution is required in addition to this application. The letter can be a brief memo, indicating support in participating in the project and the team leaders. It should indicate how participation in BOOST aligns with your hospital's priorities and what resources are anticipated to be offered to the team to assist in the project's success.

If accepted, there is a tuition fee of $19,000/hospital.

Contact Jenna Goldstein to submit your letter of support or if there are any questions.

* 1. Hospital/Institution:

* 2. Applicant First Name:

* 3. Applicant Last Name:

* 4. Degree 1:

* 5. Degree 2:

* 6. Address:

* 7. City:

* 8. State:

* 9. Postal Code:

* 10. Phone:

* 11. Email Address:

* 12. Are you or a key member of your team an SHM member in good standing?

* 13. Years in practice:

* 14. Who is your employer?

* 15. Hospital Name:

* 16. Address:

* 17. City/State/Zip

* 18. Type of facility (please check all that apply):

* 19. Is the facility part of a system?

* 20. Number of staffed beds:

* 21. Which types of units does the hospital have? (Please check all that apply)

* 22. Do you have medical or surgical housestaff at your hospital?

* 23. Does the hospital have computerized physician order entry?

* 24. Does the hospital have an electronic health (medical) record?

* 25. How/where did you first hear about Project BOOST?