PQCNC Cardiac Conditions in Obstetric Care Perinatal Quality Improvement Team (PQIT)

1. Our facility's name and address are below:

Space Cell	Name of Facility	Address	City	State	Zip
1	1: Name of Facility	1: Address	1: City	1: State	1: Zip

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(s). You may return as frequently as necessary to complete the roster for your team

2. Our team contact information is below:

Space Cell	Last Name	First Name	Email	Phone	Title/Position
Facility Leadership Champion (hospital executive, etc.)	Facility Leadership Champion (hospital executive, etc.): Last Name	Facility Leadership Champion (hospital executive, etc.): First Name	Facility Leadership Champion (hospital executive, etc.): Email	Facility Leadership Champion (hospital executive, etc.): Phone	Facility Leadership Champion (hospital executive, etc.): Title/Position
Perinatal Quality Improvement Team (PQIT) Leader	Perinatal Quality Improvement Team (PQIT) Leader: Last Name	Perinatal Quality Improvement Team (PQIT) Leader: First Name	Perinatal Quality Improvement Team (PQIT) Leader: Email	Perinatal Quality Improvement Team (PQIT) Leader: Phone	Perinatal Quality Improvement Team (PQIT) Leader: Title/Position
Physician Champion - Maternal	Physician Champion - Maternal: Last Name	Physician Champion - Maternal: First Name	Physician Champion - Maternal: Email	Physician Champion - Maternal: Phone	Physician Champion - Maternal: Title/Position
Nurse Manager Champion - Maternal	Nurse Manager Champion - Maternal: Last Name	Nurse Manager Champion - Maternal: First Name	Nurse Manager Champion - Maternal: Email	Nurse Manager Champion - Maternal: Phone	Nurse Manager Champion - Maternal: Title/Position
Data Entry Contact	Data Entry Contact: Last Name	Data Entry Contact: First Name	Data Entry Contact: Email	Data Entry Contact: Phone	Data Entry Contact: Title/Position
IT Support	IT Support: Last Name	IT Support: First Name	IT Support: Email	IT Support: Phone	IT Support: Title/Position
Pt/Family Team Member	Pt/Family Team Member: Last Name	Pt/Family Team Member: First Name	Pt/Family Team Member: Email	Pt/Family Team Member: Phone	Pt/Family Team Member: Title/Position
Pt/Family Team Liasion (staff member who will work closest with pt/family member)	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Last Name	Pt/Family Team Liasion (staff member who will work closest with pt/family member): First Name	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Email	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Phone	Pt/Family Team Liasion (staff member who will work closest with pt/family member): Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position
Team Member	Team Member: Last Name	Team Member: First Name	Team Member: Email	Team Member: Phone	Team Member: Title/Position

PQCNC Cardiac Conditions in Obstetric Care Perinatal Quality Improvement Team (PQIT)

Cardiac Conditions in Obstetric Care Roster