Contact Information

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* Contact Information

Availability
During which hours are you available?

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* Availability
During which hours are you available?

Are you available to travel? Any required travel expenses will be reimbursed

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* Are you available to travel? Any required travel expenses will be reimbursed

Interests
Tell us in which areas you are interested

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* Interests
Tell us in which areas you are interested

Statement of Interest
Describe what prompted your interest in patient safety

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* Statement of Interest
Describe what prompted your interest in patient safety

Previous Experience
Summarize any prior experience related to patient safety/healthcare advocacy

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* Previous Experience
Summarize any prior experience related to patient safety/healthcare advocacy

Other Information
Summarize any other information you think is important

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* Other Information
Summarize any other information you think is important

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