National EMS QI Partnership Enrollment Form

Reduction in the use of Lights and Siren

We have had a lot of interest in this project. Our primary slots are full. Please fill out the form below and we will add your system on a wait list as we expect that some of the systems that have registered may decide not to participate. 
 
Thank you for your interest in the EMS Quality Improvement Partnership (EQuIP). To participate in this national quality improvement partnership, please complete the following Enrollment Form. 
 
As a participant in this collaborative, you will be committed to:
·      Participate in up to (4) virtual Learning Sessions (~4 hours per session).
·      Share performance data on the use of lights-and-siren for your agency/system.
·      Implement strategies from the change package for improvement and share your experience with the larger learning collaborative.
 
All participating agencies/systems will receive:
·      Access to education and shared learning from content experts
·      Access to the online shared learning and quality improvement platform
·      Credit as a participant in the first-ever national collaborative in EMS with credit in the final published change package. 
·      Improved safety for your providers, patients, and community!


1.Agency/Organization Name:
2.Street Address
3.We would like to participate as
4.Key Contact for Agency or System
5.Contact for Agency Within Your System
6.Contact for Agency Within Your System
7.Contact for Agency Within Your System
8.Contact for Agency Within Your System
9.Contact for Agency Within Your System
10.Contact for Agency Within Your System
11.Contact information for anyone else you'd like to keep updated on this project and have access to the online platform.
12.Contact information for anyone else you'd like to keep updated on this project and have access to the online platform.
13.Contact information for anyone else you'd like to keep updated on this project and have access to the online platform.
14.Contact information for anyone else you'd like to keep updated on this project and have access to the online platform.
15.Contact information for anyone else you'd like to keep updated on this project and have access to the online platform.
16.If you have more agencies or people you'd like to keep updated on this project let us know your needs here and we will contact you.
17.What other questions, comments, or concerns do you have about this project?