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Stroke CHAMPION Contact info Sheet
*
1.
About You
(Required.)
Name
(First, Last)
Email
(
professional emails only,
no personal emails please)
Phone Number
Credentials
(RN, MD, PhD, ARNP, etc)
Title
(what does your professional signature state)
2.
About You- please indicate your Role (at your hospital/institution/ agency
Researcher
Clinician (stroke coordinator; medical director; PT, EMS, etc)
Leadership- Hospital Admin (CNO, CEO, CMO, Quality Control, etc)
Government (advocacy, legislator, etc)
Student (PhD, MS, MD, Fellow, Resident, etc)
Other (please specify)
*
3.
About Your Hospital/Institution
(Required.)
Institution/Hospital/ Agency
Address
County
Zip/Postal Code
State
4.
Please list any other hospitals or sites your represent:
Hospital 1
Hospital 2
Hospital 3
Hospital 4
Hospital 5
*
5.
Would you like to be added to the Florida Stroke Registry listserv?
(Required.)
Yes
No
*
6.
Would you like to be considered to have access to the "Account Holders Only" section of the Florida Stroke Registry website?
(Required.)
Yes
No
Current Progress,
0 of 6 answered
