TALK Wave 2 Enrollment

Thank you for your interest in the Transforming Adolescent Care Learning Collaborative Wave 2 (TALK)! Please complete the following information pertaining to your practice and your TALK Core Team for registration into the Learning Collaborative.

Should you have any questions regarding the collaborative, please contact Kaley Langenderfer at (614) 846-6258 or via email at klangenderfer@ohioaap.org.

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* 1. Please enter your Practice information:

Practice Name:

Street Address:

Suite Number/Building Number:

City:

State:

Zip Code:

Telephone Number:

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* 2. Why are you interested in joining this collaborative?

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* 3. Who will be the TALK Physician Leader for the project?

First Name:

Last Name:

Credentials:

Preferred Telephone Number:

Email Address:

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* 4. Which of the following do you currently use, or have the potential to use, to track data within your practice?

Manual chart review

Electronic Medical Record (EMR)

Registry

Other (please specify)