Project BOOST Mentoring Program Application

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 jgoldstein@hospitalmedicine.org to submit your letter of support or if there are any questions.

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* 1. Hospital/Institution:

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* 2. Applicant First Name:

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* 3. Applicant Last Name:

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* 4. Degree 1:

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* 5. Degree 2:

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* 6. Address:

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* 7. City:

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* 8. State:

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* 9. Postal Code:

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* 10. Phone:

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* 11. Email Address:

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

Yes

Other

Other (please specify):

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* 13. Years in practice:

0-4

5-10

11-20

20+

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* 14. Who is your employer?

Hospital or hospital corporation

Academic institution

Hospital medicine or multi-specialty group that contracts with hospital

Independent hospitalists

Other

Other (please specify)

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* 15. Hospital Name:

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* 16. Address:

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* 17. City/State/Zip

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

University medical center

Community teaching hospital

Community hospital (non-teaching)

County or publicly funded safety net hospital

Veterans Affairs (VA) hospital

Other

Other (please specify)

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* 19. Is the facility part of a system?

Yes

If Yes, what system?

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* 20. Number of staffed beds:

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

Acute care

Skilled nursing facility

Rehabilitation unit

Behavioral health unit

Other

Other (please specify)

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

Yes

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

Yes

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

Epic

Meditech

Cerner

None

Other

Other (please specify)

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

SHM website homepage

SHM Care transitions Implementation Toolkit page

Email from SHM

SHM Annual Meeting

The Hospitalist

Word of mouth/colleague

Other

Other (please specify)