Project Participation Interest Form

Please complete and submit this form to OneCity Health at DSRIPSUPPORT@nychhc.org by Monday, April 18th, 2016. Note that submission of this form will serve as your attestation to meeting the qualifications/criteria specified in the Project Participation Opportunity.

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* 1. Partner Contact Information

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* 2. Number of existing staff with Insignia PAM training:

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* 3. Technology to support documenting, tracking and reporting (check all that apply):

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* 4. Projected number of bundled service units in a 30-day period:

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* 5. Number of staff allocated to attend "Training of Trainers" on Insignia PAM-10 survey:

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* 6. Languages supported by Partner (check all that apply):

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* 7. Hot spot areas in which Partner is willing to operate (list all that apply in the 'Other' category):

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