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PMP Toolkit Registration Form
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1.
First Name
(Required.)
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2.
Last Name
(Required.)
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3.
Email Address
(Required.)
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4.
Practice Name
(Required.)
5.
Practice Address
Street
City
Zip Code
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6.
What is your credential?
(Required.)
MD
DO
DNP
NP
PA
Other (please specify)
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7.
What is your specialty?
(Required.)
General Pediatrics
Family Medicine
Other (please specify)
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8.
Which of the following is the best description of your practice?
(Required.)
Solo practice
Group practice
Hospital-owned
Federally Qualified Health Center (FQHC)
Academic Health Center
Other (please specify)
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9.
Have you participated in PMP activities/used PMP resources in the past?
(Required.)
Yes, I participated in the PMP QI program
Yes, I attended a PMP training
Yes, I have used PMP resources
No
Other (please specify)
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10.
How did you learn about the toolkit? (Select all that apply)
(Required.)
Ohio AAP Today newsletter
Personal email from Ohio AAP
Personal phone call from Ohio AAP
Other Ohio AAP email
Ohio AAP Annual Meeting
Ohio AAP live webinar/training
Ohio AAP podcast
Ohio AAP Facebook
Ohio AAP Instagram
Ohio AAP Twitter
Ohio AAP LinkedIn
Ohio Association of Community Health Centers listserv or social media
Ohio Association of Physician Assistants listserv or social media
Ohio Association of Advanced Practice Nurses listserv or social media
Ohio Osteopathic Association listserv or social media
Word of mouth (e.g., colleague, friend, patient/family)
Other (please specify)
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11.
What are your top 1-2 reasons for requesting the PMP toolkit?
(Required.)