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* 1. Please select your hospital.

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* 2. Please provide contact information for the person responsible for signing Data Sharing Agreements for your department (this is typically an OB Chief or Chair, or Medical, Nursing, or Quality Improvement Director).

Click HERE to check if your hospital has already signed the AIM MOU with Betsy Lehman Center!

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* 3. Please provide contact information for your department's EQT Obstetric Champion (MD, DO, or CNM)

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* 4. Please provide contact information for your department's EQT Nursing Champion (RN)

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* 5. Please use the space below to provide contact information (name, title, email address) for any additional EQT bundle team members.

This could include staff, students, or residents in: obstetrics, nursing, midwifery, pediatrics, neonatology, quality improvement, administration, legal, anesthesia, emergency department, family medicine, blood bank, public health, education or social work.

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* 6. Would you like to complete/update your hospital's team roster for any other AIM Bundle?

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