Welcome to the APhA Foundation IMPACT Care Transformation Network Interest Form

Please complete the information below to express your interest in the APhA Foundation's
IMPACT Care Transformation Network to have your organization considered for collaborating
on future patient-centered, team-based care service delivery opportunities.

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Please provide contact information about your organization.

IMPACT Care Transformation Network Organization *

Primary Contact First Name *

Primary Contact Last Name *

Organization Street Address *

Organization City *

State *

Zip Code *

Primary Contact Phone *

Primary Contact e-Mail Address *

Primary Contact Cell Phone

Primary Contact Fax Number

Primary Contact Title, Credentials and Role *

0/512 characters

What is your organization's practice setting? *

Independent Community Practice

Chain Community Practice (10 or more locations)

Food/Pharmacy, Chain Community Practice

Hospital Community Practice

Ambulatory Care Clinic Practice

Mass Market Retailer Practice

Other Other

Which of the following initiatives would your organization be interested in participating in? (Please check all that apply.) *

IMPACT Diabetes (Diabetes Prevention / Medicare DPP)

Project IMPACT: Vaccine Confidence

HPV

CVH

Would you like to tell us more about your practice setting today? *

Yes

Not right now

Please describe the patient population mix in your practice.

*

Please describe the staffing and patient care area resources that are available in your practice.

*

Please describe your practice information management technology resources that you believe will support your participation in our practice-based research collaboration. *

Please describe your ability to prioritize this practice-based research activity in your practice. *

Please describe your training and experience in participating in practice-based research. *

IMPACT Care Transformation Network Practice Site Characteristics

Does your site have access to a computer with high speed internet access for data entry? *

Yes

No

Does your site have experience in Electronic Data Capture/Remote Data Entry for clinical studies? *

Yes

No

Does your site have available space for participants to complete questionnaires? *

Yes

No

Does your site have dedicated separate room for participants to conduct proposed study unobserved? *

Yes

No

Does your site have dedicated secure space for storage of study related materials? *

Yes

No

Does your site have space for archival of data after completion of a study? *

Yes

No

If yes to above, please provide the details and procedures. If no, please specify a location where the documents can be stored. *

ADDITIONAL COMMENTS

Additional Comments or Questions