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.

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What is your organization's practice setting? *
Which of the following initiatives would your organization be interested in participating in? (Please check all that apply.) *
Would you like to tell us more about your practice setting today? *

IMPACT Care Transformation Network Practice Site Characteristics

Does your site have access to a computer with high speed internet access for data entry? *
Does your site have experience in Electronic Data Capture/Remote Data Entry for clinical studies? *
Does your site have available space for participants to complete questionnaires? *
Does your site have dedicated separate room for participants to conduct proposed study unobserved? *
Does your site have dedicated secure space for storage of study related materials? *
Does your site have space for archival of data after completion of a study? *