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* 1. What is your full name?

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* 2. What is your State Partner? Please use full State Hospital Association/QIN/QIO name (ex: Florida Hospital Association; Great Plains QIN/QIO)

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* 3. What is your organization?

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* 4. What is your current position/department?

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* 5. What is your email address?

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* 6. Who are the members of your team? What are their titles?

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* 7. Do you currently have a Patient Family Advisory Council? 

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* 8. What is it that you are most hoping to gain from this fellowship?

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