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Perinatal Quality Collaborative of North Carolina

Page One

PQCNC AIM clOUDi 3.0 Roster Form

1. Our facility's name and address are below:
Space Cell Name of FacilityAddressCityStateZip
Please fill out the positions that you know, leaving blank those about which you are unsure, and submit to ensure that you begin receiving emails/newsletters/etc. and are kept up-to-date on the initiative.  You may return as frequently as necessary to complete the roster for your team
2. Our team contact information is below:
Space Cell Last NameFirst NameEmailPhoneTitle/Position
Hospital Executive Champion
Project Team Leader
Physician Champion - Maternal
Physician Champion - Newborn
Nurse Manager Champion - Maternal
Nurse Manager Champion - Newborn
Social Work Contact
Pharmacy Contact
Data Entry Contact
IT Support
Pt/Family Team Member
Pt/Family Team Liasion (staff member who will work closest with pt/family member)
Team Member
Team Member