This form should only be completed by the primary CoC contact at each CoC accredited institution.

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* 1. Individual Name

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* 2. CoC Accredited Facility Name

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* 3. CoC Accredited Facility FIN

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* 4. Which electronic medical record (EMR) does your institution use?

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* 5. Please estimate the number of surgeons you anticipate would use a synoptic reporting tool at your institution.

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* 6. How does your institution plan to comply with the synoptic reporting requirements of CoC Standards 5.3-5.6?

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