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PQCNC AIM clOUDi Prenatal Pilot Roster Form

Page One

1. Our facility's name and address are below:
Space Cell Name of FacilityAddressCityStateZip
Please provide information for all identified team members, leaving blank those about which you are unsure, and submit to ensure that your team members are kept up-to-date on the initiative.  You may return to this form to update the roster for your team as needed. 
2. Our team contact information is below:
Space Cell Last NameFirst NameEmailPhoneTitle/Position
Project Team Leader
OB Provider Champion
Nursing Champion
Social Work / Case manager
Patient/Family Team Member
Team Member
Team Member