REGISTERING A PATIENT
|
|
- Alexandrina Marshall
- 6 years ago
- Views:
Transcription
1 REGISTERING A PATIENT Patient Eligibility It is important for the institution staff to review all eligibility criteria and follow-up requirements. A patient failing to meet all protocol eligibility requirements may not be registered. A patient cannot be canceled from a protocol once he or she is registered, regardless of the surrounding circumstances. Typically, in older studies, once a patient number is assigned, the patient is followed for life. In recent studies this has become less stringent and follow up may be required for a limited number of years. Always refer to section 14 of the protocol to verify how long you must follow the patient. The following steps should be taken to prepare for the registration: 1. Review eligibility per Section 5.0 of the protocol. 2. Review all amendments which could affect eligibility. 3. Confirm that all legal requirements have been met. Assure that the protocol has undergone IRB approval within the last year and note IRB approval date. Verify that the informed consent has been signed. 4. Verify that all appropriate pretreatment tests have been completed within the time frame defined in the protocol. Chapter 12 - Page 1 ORP Manual Version 3.0
2 Timing Guidelines for Prestudy Labs, Measurements and H & P These guidelines may differ on a study-specific basis and will be clearly stated in the protocol. In the absence of study-specific guidelines, the following guidelines will be strictly applied. To be completed within 28 DAYS prior to registration * Blood work or other body fluid analyses (urinalysis, creatinine clearance) required for determination of eligibility. * X-rays, scans or physical examination utilized for tumor measurement on Phase II or Phase III studies. * History and Physical To be completed within 42 DAYS prior to registration * Baseline exams used for screening (e.g., audiogram, PFT) other than blood or body fluid analysis. * X-rays and scans of non-measurable disease or of uninvolved organs on Phase II or Phase III studies. To be completed within 56 DAYS prior to registration * X-rays, scans, ultrasounds, etc. used to establish disease free status on adjuvant studies. 5. Check the anticipated treatment start date. Do not register a patient if treatment has already started or if treatment is anticipated to begin more than three working days following registration unless the protocol allows otherwise. 6. When pathology review is required, confirm with the pathologist that the materials are available for submission. 7. When radiation therapy rapid review is required, notify the radiation therapy department that materials must be submitted within 48 hours following the first treatment fraction and that the treatment guidelines in the protocol must be followed. If a pre-registration radiation therapy consult is required, details will be included in the eligibility section of the protocol. 8. Order investigational drugs, as appropriate. After a protocol with an investigational new drug is approved by an institution's IRB, some studies will allow the institution to order a "loading dose" from the NCI (enough for one patient), even though the institution has not yet put a patient on protocol. Section 3 of the protocol will have ordering instructions. Chapter 12 - Page 2 ORP Manual Version 3.0
3 9. Check protocol sections 12 and 15 for any special requirements. Some studies allow specimen submission prior to registration. These can be logged and shipped in the SWOG Specimen Tracking System and a SWOG patient number will be assigned. It is imperative to use this SWOG patient ID number during the registration in the Oncology Patient Enrollment Network (OPEN) system. 10. Verify that the patient is scheduled to return to the institution for follow-up as required. Refer to the Study Calendar in the protocol for scheduling guidelines. In calculating days of tests and measurements, the day a test or measurement is done is considered day 0. Therefore, if a test is done on a Monday, the Monday 4 weeks later would be considered Day 28. This allows for efficient patient scheduling without exceeding the guidelines. If Day 28, 42 or 56 falls on a weekend or holiday, the limit may be extended to the next working day. The SWOG Data Operations Center will not make exceptions to the eligibility criteria in the protocol without a written amendment to the protocol from the Operations Office. Amendments must be recommended by the study chair, approved by the disease committee chair, the Headquarters Executive Officer, the statistician of record, and the NCI. Once approved at all levels, the amendment to the protocol and revised checklist are circulated to the Group. No one in the Group is authorized to make an exception to eligibility criteria unless an error is discovered in the protocol relating to the exception. Section 5.0 of the Protocol Section 5.0 of the protocol is designed to assist the oncology research professional in identifying an eligible patient. Patients must meet all criteria prior to completing the registration. 1. Using the patient's medical record, answer the eligibility and exclusion questions. Record laboratory results using actual laboratory report. Review the pathology report to confirm the histology. Read the patient's medical history to confirm eligibility. Review results of diagnostic tests to confirm stage of disease. Verify that all required tests were performed within the correct time frame. Indicate the date of laboratory values, tumor measurements, dates of diagnosis or scans, even if a line is not provided for this information. This provides a cross-reference to the information you obtained in completing the onstudy form, which is especially helpful in locating data for quality assurance audits. The answers to these questions asked at time of registration are viewed as an oath that the patient meets the criteria for entry to the study. When a patient does not qualify for entry to the study based on the answers, do not attempt to register the patient; no exceptions are made to the protocol eligibility criteria. Chapter 12 - Page 3 ORP Manual Version 3.0
4 The Study-Specific Registration and Onstudy Forms The majority of SWOG protocols contain study-specific registration and prestudy or onstudy forms. The registration form must be completed prior to initiating the registration. Section 5.0 of the protocol is to be used as a worksheet to ensure that all eligibility criteria have been satisfied. 1. Complete all information requested on the Registration Form: the patient's initials, zip code of residence, institution and investigator numbers, date patient signed the informed consent and HIPAA authorization and the projected start date of treatment. 2. The Registration Form must be signed and dated by the treating investigator prior to registration. This form is not submitted to SWOG, but must be in your records for review by auditors. 3. Using the patient s medical record and eligibility criteria per Section 5.0 of protocol, complete the study-specific onstudy form. In addition to demographic data, sections may include patient characteristics, disease description, prior treatment, stratification and descriptive factors. OPEN Registration Guidelines Patients must be registered prior to initiation of treatment, no more than three working days prior to the planned start of treatment unless otherwise stated in section 13.1 of the protocol. Effective October , registrations are to be performed via the Oncology Patient Enrollment Network (OPEN). The individual registering the patient must have completed the appropriate SWOG Registration Worksheet. The completed form must be referred to during the registration but should not be submitted as part of the patient data. OPEN will also ask additional questions that are not present on the SWOG Registration Worksheet. The individual registering the patient must be prepared to provide answers to the following questions: a. Institution CTEP ID b. Protocol Number c. Registration Step d. Treating Investigator e. Credit Investigator f. Patient Initials g. Patient s Date of Birth h. Patient Social Security Number (SSN is desired, but optional. Do not enter invalid numbers.) i. Country of Residence j. ZIP Code k. Gender (select one): Female Gender Male Gender Chapter 12 - Page 4 ORP Manual Version 3.0
5 l. Ethnicity (select one): Hispanic or Latino Not Hispanic or Latino Unknown m. Method of Payment (select one): Private Insurance Medicare Medicare and Private Insurance Medicaid Medicaid and Medicare Military or Veterans Sponsored NOS Military Sponsored (Including Champus & Tricare) Veterans Sponsored Self Pay (No Insurance) No Means of Payment (No Insurance) Other Unknown n. Race (select all that apply): American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Unknown All site staff will use OPEN to enroll patients to this study. OPEN is a web-based application and can be accessed at or from the OPEN tab on the CTSU members side of the website at or from the OPEN Patient Registration link on the SWOG CRA Workbench. a. Prior to accessing OPEN site staff should verify the following: All eligibility criteria have been met within the protocol stated timeframes. Site staff should refer to Section 5.0 to verify eligibility. All patients have signed an appropriate consent form and HIPAA authorization form (if applicable). b. Access requirements for OPEN: Site staff will need to be registered with CTEP and have a valid and active CTEP-IAM account. This is the same account (user ID and password) used for the CTSU members' web site. To perform registrations on SWOG protocols you must have an equivalent 'Registrar' role on the SWOG roster. Role assignments are handled through member@swog.org. Note: The OPEN system will provide the site with a printable confirmation of registration and treatment information. Please print this confirmation for your records. c. Further instructional information is provided on the OPEN tab on the CTSU members side of the website at or at For any additional questions contact the CTSU Help Desk at or ctsucontact@westat.com. Chapter 12 - Page 5 ORP Manual Version 3.0
6 Registrations must take place no more than three working days prior to the planned start of treatment unless otherwise stated in section 13.1 of the protocol. Such allowances sometimes are made for studies requiring time for ordering protocol specific agents or in which surgery or radiation therapy are the first treatment modalities following registration. This includes studies requiring placement of a Hickman catheter or portacatheter. However, actual scheduling of radiation therapy or surgery should take place immediately following registration. If scheduling cannot be done immediately (e.g., patient is unsure when he/she will be available, surgeon is out of town for an extended time), the registration should be delayed. Chapter 12 - Page 6 ORP Manual Version 3.0
QUALITY ASSURANCE PROGRAM
QUALITY ASSURANCE PROGRAM Elaine Armstrong, MS Quality Assurance Manager PURPOSE Verify accuracy of submitted data Verify compliance with protocol and regulatory requirements Provide educational support
More informationS1404: GENERAL DATA MANAGEMENT UPDATES
S1404: GENERAL DATA MANAGEMENT UPDATES SWOG 2018 SPRING GROUP MEETING Krystle Pagarigan, BS Clinical Research Data Coordinator SWOG Statistics and Data Management Center (SDMC) Overview Brief History of
More informationCollege of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type)
CCAMPIS# Date Received College of Lake County Children s Learning Center Child Care Access Means Parents in School CCAMPIS Grant Application (Please print or type) Approved Denied: Date: 1. Student-parent
More informationIf you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study.
A Note to Our Patient: Your physician will be receiving a copy of your results via fax within two business days. Please contact your physician to go over your results and to obtain a copy of your report.
More informationVolunteer Application Package
Volunteer Application Package April, 2016 This program is supported by the Georgia Department of Human Services/Division of Aging Services/GeorgiaCares Program with financial assistance, in whole or in
More informationEMPLOYMENT APPLICATION
EMPLOYMENT APPLICATION Page 1 of 3 This Employment Application will remain active for one year from the date of completion APPLICANT INFORMATION Last Name First M.I. Date Street Apartment/Unit # City State
More informationSTATE FISCAL YEAR 2017 ANNUAL NURSING HOME QUESTIONNAIRE (ANHQ) July 1, 2016 through June 30, 2017
STATE FISCAL YEAR 2017 ANNUAL NURSING HOME QUESTIONNAIRE (ANHQ) July 1, 2016 through June 30, 2017 - IMPORTANT NOTICE ABOUT SURVEY ACCURACY AND COMPLIANCE The information and data collected through this
More informationSCHOOL OF NURSING POLICY
SCHOOL OF NURSING POLICY SUBJECT: Academic Affairs TITLE: Graduate Program Student Scholarship Responsible Executive: Assistant Dean for Graduate Programs Responsible Office: Business Office CODING: 06-01-05-16:00
More informationResponsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self
Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
More informationCarolinas Collaborative Data Dictionary
Overview Carolinas Collaborative Data Dictionary This data dictionary is intended to be a guide of the readily available, harmonized data in the Carolinas Collaborative Common Data Model via i2b2/shrine.
More informationEMPLOYMENT APPLICATION
Travis County Human Resources Management Department 1010 Lavaca Street, 2 nd Floor (corner of West 11th & Lavaca) www.co.travis.tx.us P.O. Box 1748 Austin, TX 78767 (512) 854-9165 Voice EMPLOYMENT APPLICATION
More information2017 SPECIALTY REPORT ANNUAL REPORT
2017 SPECIALTY REPORT ANNUAL REPORT National Commission on Certification of Physician Assistants Table of Contents Message from the President... 3 About the Data Collection and Methodology...4 All Specialties....
More informationFREE TRAINING CAREER SUPPORT SERVICES
DOL H-1B Ready To W ork Grant FREE TRAINING CAREER SUPPORT SERVICES Upcoming Courses Will Include: Pr Funding for TWIC card is available Participating Partner CollegesTrainings Offered: CC RCrafts Project
More informationHome Health Quality Improvement Campaign
Home Health Quality Improvement Campaign Description of Monthly Report for Improvement in Oral Medications Monthly Report for Improvement in Management of Oral Medications All data displayed illustrate
More informationCedars HOPE, Inc. RESIDENT APPLICATION
Cedars HOPE, Inc. RESIDENT APPLICATION Agency Name: Agency address: REFERRING AGECNY INFORMATION Fax: Referring Person Name: Contact Email Date of Referral: / / Name: APPLICANT INFORMATION Date of birth:
More informationAdministrative Billing Data
Administrative Billing Data Patient Identification and Demographic Information: From UB-04 Data or Medical Record Face Sheet. Note: When you go to enter data on this case, the information below will already
More informationVOLUNTEER APPLICATION
Please return to: Mount Nittany Medical Center Volunteer Services Department 1800 East Park Avenue State College, PA 16803 814.234.6170 VOLUNTEER APPLICATION Application Date Assignment Interview Date!
More informationSTERILIZATION CONSENT FORM INSTRUCTIONS
STERILIZATION CONSENT FORM INSTRUCTIONS In accordance with Title 42 Code of Federal Regulations (CFR) 50, Subpart B, all sterilizations require a valid consent form. The consent form can be downloaded
More informationData Quality Tools: SWOG Expectation Reports and CTSU Data Quality Portal
Data Quality Tools: SWOG Expectation Reports and CTSU Data Quality Portal Phyllis Goodman, M.S. Coordinating Statistician Institution Performance SWOG Statistical Center Why Do Patients Participate on
More informationADDING A PRACTITIONER FORM
This form is applicable for Medicaid AND Passport Advantage provider networks. YOU ONLY NEED TO SUBMIT THIS FORM ONE (1) TIME. ADVANTAGE (HMO SNP) ADDING A PRACTITIONER FORM Must complete entire form for
More information2015 All-Campus Career Fair Student Survey
2015 All-Campus Career Fair Student Survey Thank you for attending the All-Campus Career Fair on March 18th. The Career Center is interested in learning about your experience at the career fair and results
More informationClarkson University Supplemental Application Class of 2021
Clarkson University Supplemental Application Class of 2021 There is no advanced placement in the Clarkson University PA program nor does the program accept transfer credit from a student previously enrolled
More informationALL MENTAL HEALTH AND SUBSTANCE USE DISORDER PROGRAMS MUST INCLUDE PSYCHOSOCIAL AND PSYCHIATRIC EVALUATIONS
COUNTY of NASSAU DEPARTMENT OF HUMAN SERVICES Office of Mental Health, Chemical Dependency and Developmental Disabilities Services 60 Charles Lindbergh Boulevard, Suite 200, Uniondale, New York 11553-3687
More informationRESPITE CARE VOUCHER PROGRAM
HELPING HANDS of VEGAS VALLEY 2320 Paseo Del Prado B-204, Las Vegas, NV 89102 (702) 633-7264 ext. 26 or Fax (702) 728-2963 RESPITE CARE VOUCHER PROGRAM Dear Applicant: Thank you for your interest in the
More informationAPPLICATION
MAYOR THOMAS C. HENRY CITY OF FORT WAYNE MAYOR S YOUTH ENGAGEMENT COUNCIL 2017-2018 APPLICATION Please mail, deliver or fax completed applications to: MAYOR S OFFICE, ATTN: KAREN L. RICHARDS 200 E. BERRY
More informationA. Are you currently a resident of the United States and 18 years of age and older?
The Polling Institute N=1,028 Likely Voters Saint Leo University Field: 10/22 10/26 October 2016 FLORIDA ballot measures The Polling Institute at Saint Leo University needs your help. We are conducting
More informationUNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR)
1 OVERVIEW OF THE UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR) University City Fire & Rescue Department Telephone: (514) 911-0129 1000 Rescue Drive University, IA 50436 City Demographics: The city has
More informationPATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD
PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD General Consent for Treatment I have the legal right to consent to medical and surgical treatment because (a) I am the patient
More informationPLEASE BE AWARE THAT YOU WILL NOT BE ABLE TO SAVE YOUR PROGRESS, SO PLEASE PREPARE ALL OF YOUR ANSWERS AND UPLOADABLE FILES IN ADVANCE.
2/26/2018 PhD Works Spring 2018 Application PhD Works Spring 2018 Application Your email address (lyl.tomlinson@stonybrook.edu) will be recorded when you submit this form. Not lyl.tomlinson? Sign out *
More informationAdult Health History
Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure
More informationAdditionally, the parent or legal guardian must provide the following documents upon registration of a new student:
Montgomery County Public Schools requires several documents upon registration of a new student. Below is a list of documents which may be downloaded and reviewed and/or completed by the parent or legal
More informationFamily Care Health Centers
Family Care Health Centers New/Established Patient Information (Please Print) Account # Date: Circle One: New Patient or Established Patient Last: First: M.I. Date of Birth: Address: City: State: Zip:
More informationAppendix A Registered Nurse Nonresponse Analyses and Sample Weighting
Appendix A Registered Nurse Nonresponse Analyses and Sample Weighting A formal nonresponse bias analysis was conducted following the close of the survey. Although response rates are a valuable indicator
More informationPlease answer the survey questions about the care the patient received from this hospice: [NAME OF HOSPICE]
CAHPS Hospice Survey Please answer the survey questions about the care the patient received from this hospice: [NAME OF HOSPICE] All of the questions in this survey will ask about the experiences with
More informationThank you, in advance, for being a partner in your care.
477 Cooper Road, Suite 220 Westerville, OH 43081 614-818-0215 Your appointment with: Dr. David H. Brown Dr. Jed W. Henry Dr. Adam J. Clemens is scheduled for. Welcome to our practice. It is our desire
More informationMedicaid Transformation Waiver New options for Long-term Services and Supports. November 18th, 2016
Medicaid Transformation Waiver New options for Long-term Services and Supports November 18th, 2016 Today s topics Initiative 2 Long-Term Services and Supports Medicaid Alternative Care (MAC) Tailored Supports
More informationIdentifying and Describing Nursing Faculty Workload Issues: A Looming Faculty Shortage
Identifying and Describing Nursing Faculty Workload Issues: A Looming Faculty Shortage Nancy Phoenix Bittner, PhD, CNS, RN Cynthia F. Bechtel, Ph.D., RN, CNE, CEN, CHSE Conflicts of Interest and Disclosures:
More informationInstructions for completion and submission
OMB No. 1121-0094 Approval Expires 01/31/2019 Form CJ-5A 2018 ANNUAL SURVEY OF JAILS PRIVATE AND MULTIJURISDICTIONAL JAILS FORM COMPLETED BY U.S. DEPARTMENT OF JUSTICE BUREAU OF JUSTICE STATISTICS AND
More informationDOL H1B-Gulf Coast Ready To Work Petrochem Grant
DOL H1B-Gulf Coast Ready To Work Petrochem Grant FREE TRAINING CAREER SUPPORT SERVICES Upcoming courses will include: NCCER Welding NCCER Pipefitting Engineering Design Graphics Non-Destructive Testing
More informationDOL H1B-Gulf Coast Ready To Work Petrochem Grant
FREE TRAINING DOL H1B-Gulf Coast Ready To Work Petrochem Grant CAREER SUPPORT SERVICES Upcoming courses will include: PAID INTERNSHIPS Welding Project Management Professional Pipefitting Lean Six Sigma
More informationChapter 12 Waiting List
Chapter 12 Waiting List Table of Contents Revision History------------------------------------------------------------------------------------------------ 12-1 Substance Abuse Waiting List Information-----------------------------------------------------------
More informationVolunteer Application
Volunteer Application I. CONTACT INFORMATION Mr. Mrs. Name (first): (middle): (last): Ms. Home Address: City: State: Zip: Phone (home): E-mail Address: (business): (cell): Birth Date: Employer/School:
More informationIT 3 Grant Funding FREE!! TRAINING AND CERTIFICATION EXAMS IT 3 SCHOLARS RECEIVE THE FOLLOWING:
IT 3 Grant Funding BECOME AN IT 3 SCHOLAR BEFORE IT S TOO LATE!!! FREE!! TRAINING AND CERTIFICATION EXAMS IT 3 SCHOLARS RECEIVE THE FOLLOWING: UP TO 2 CLASSES & 2 CERTIFICATION EXAMS PAID FOR BY THE IT
More informationInstructions for completion and submission
OMB No. 1121-0094 Approval Expires 01/31/2019 Form CJ-5 2017 ANNUAL SURVEY OF JAILS FORM COMPLETED BY U.S. DEPARTMENT OF JUSTICE BUREAU OF JUSTICE STATISTICS AND ACTING AS COLLECTION AGENT: RTI INTERNATIONAL
More informationDOL H1B IT 3 Grant Funding FREE!! TRAINING AND CERTIFICATION EXAMS IT 3 SCHOLARS RECEIVE THE FOLLOWING:
IT 3 Grant Funding FREE!! TRAINING AND CERTIFICATION EXAMS SAP - Human Resources SAP - Materials Management Ethical Hacking & Pen Testing Cloud Computing ITIL Bootcamp Network+ Bootcamp BECOME AN IT 3
More informationHOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA
STATE OF MINNESOTA MINNESOTA DEPARTMENT OF VETERANS AFFAIRS HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA TENNESSEN WARNING YOUR PRIVACY RIGHTS The State of Minnesota and its partners have committed to
More informationMESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018
MESA Summer Academy: Solar System Mission Possible Application Deadline: June 1, 2018 Early Bird Discount Deadline: May 1, 2018 Program Description Get a head start on your career in space exploration
More informationNEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:
Patient s Name: NEW PATIENT PACKET Last Middle First Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone Email Address: Driver s License #: DOB: Gender: Male Female
More informationPLEASE BE AWARE THAT YOU WILL NOT BE ABLE TO SAVE YOUR PROGRESS, SO PLEASE PREPARE ALL OF YOUR ANSWERS AND UPLOADABLE FILES IN ADVANCE.
6/12/2018 PhD Works Summer 2018 Application PhD Works Summer 2018 Application Your email address (lyl.tomlinson@stonybrook.edu) will be recorded when you submit this form. Not lyl.tomlinson? Sign out *
More informationAMERICAN AMBULANCE SERVICE, INC.
AMERICAN AMBULANCE SERVICE, INC. Proud to be a tobacco and smoke-free environment ONE AMERICAN WAY, NORWICH, CT 06360 VOLUNTEER APPLICATION GENERAL INFORMATION Date Name Last First MI Address Street City
More informationLast Name First Name M.I. Name You Prefer. City State Zip Address. Daytime Phone Evening Phone Best Time to Call. City State If yes, where?
GENERAL INFORMATION Last Name First Name M.I. Name You Prefer Mailing Address How long at this address? City State Zip County If less than a year, previous address How long have you resided in the county?
More informationTRANSFER PROGRAM APPLICATION AND ADMISSION INFORMATION
Department of Nursing 2088 North Beale Road Marysville CA 95901 (530) 741-6784 http://nursing.yccd.edu TRANSFER PROGRAM APPLICATION AND ADMISSION INFORMATION Yuba College offers a full-time Associate Degree
More informationEqual Employment Opportunity Self-Identification Applicant Survey
Equal Employment Opportunity Self-Identification Applicant Survey Applicant Name: Date: Position Applied For: Survey of Sex, Ethnic Group and Race Our organization is an equal opportunity employer and
More informationOklahoma Department of Career and Technology Education
Oklahoma Department of Career and Technology Education Information Commons September 2016 Oklahoma Healthcare Support Occupations Parameters Occupations Code Description 31-0000 Healthcare Support Occupations
More informationAPPLICATION FOR EMPLOYMENT
TICE TO APPLICANTS AND EMPLOYEES Screening tests for alcohol and illegal drug use may be required before hiring and during your employment here. APPLICATION FOR EMPLOYMENT We consider applications for
More informationSurvey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D)
Survey of Program Training Needs (TCU PTN) Program Director Version (TCU PTN-D) To be completed by Program Director Please answer the following questions by filling in the circle that describes your substance
More informationYear In Review: FY2015
The Year In Review: FY2015 is a high level summary of activity for the last fiscal year compiled by the CCHHS BI team. For any questions, please contact Amanda Grasso at agrasso@cookcountyhhs.org. Facility
More informationTRANSFER Associate Degree Nursing PROGRAM APPLICATION AND ADMISSION INFORMATION
Department of Nursing 2088 North Beale Road Bldg. 2100, Room 2105 Marysville CA 95901 (530) 741-6784 http://nursing.yccd.edu TRANSFER Associate Degree Nursing PROGRAM APPLICATION AND ADMISSION INFORMATION
More informationEqual Employment Opportunity Self-Identification Applicant Survey
Equal Employment Opportunity Self-Identification Applicant Survey Applicant Name: Date: Position Applied For: Survey of Sex, Ethnic Group and Race Our organization is an equal opportunity employer and
More informationEmployee EEO Self-Identification Form
CONFIDENTIAL Employee EEO Self-Identification Form Notice - Completion of this form is voluntary. We are an Affirmative Action, Equal Opportunity Employer. Our employment decisions are made without regard
More informationPhysical Therapy Assistant Occupation Overview
Physical Therapy Assistant Occupation Overview Emsi Q1 2018 Data Set March 2018 Western Technical College 400 Seventh Street La Crosse, Wisconsin 54601 608.785.9200 Emsi Q1 2018 Data Set www.economicmodeling.com
More informationScientific Research Disaster Recovery Grant (Cycle 1) Contact Information
Scientific Research Disaster Recovery Grant (Cycle 1) Contact Information Applications Due: January 3, 2018, 5:00 PM ET Before the form is completed, you may click "Save & Continue" at the bottom of the
More informationWikiLeaks Document Release
WikiLeaks Document Release 2, 2009 Congressional Research Service Report RS22452 United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom Hannah Fischer, Knowledge
More informationFIRE RECRUIT CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS MINIMUM QUALIFICATIONS
>0?.\. CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS Announces an Examination for FIRE RECRUIT ANNOUNCEMENT OPENS: THURSDAY, JULY 19, 2018 AT 9:30 A.M. APPLICATION DEADLINE: FRIDAY, AUGUST l7, 2018 AT
More informationWork-Study Internship Application
Work-Study Internship Application 1 Centre Street, Room 2435, New York, NY 10007 212-386-0057 212-669-3633 (fax) psc@dcas.nyc.gov nyc.gov/psc Department of Citywide Administrative Services Lisette Camilo
More informationLVN to RN PROGRAM APPLICATION AND ADMISSION INFORMATION
Department of Nursing 2088 North Beale Road Marysville CA 95901 (530) 741-6784 http://nursing.yccd.edu LVN to RN PROGRAM APPLICATION AND ADMISSION INFORMATION Yuba College offers a LVN to Associate Degree
More informationRNDC does not discriminate on the basis of age, race, sex, creed, or disability. Equal Opportunity Lender
PLEASE PRINT CLEARLY OR TYPE: DEPARTMENT OF BUSINESS AND INDUSTRY HOUSING DIVISION WEATHERIZATION ASSISTANCE PROGRAM APPLICATION A. APPLICANT INFORMATION HOME WORK NAME: PHONE: PHONE: (Last, First, MI)
More information2017 Claim Form 1. Choose one:
2017 Claim Form 1. Choose one: Family Planning Program: DSHS Family Planning Program (DFPP) 1a. DFPP only: Partial Pay No Pay 2a. Billing Provider 2b. Billing provider 3. Provider Name 4. Eligibility Date
More informationEQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134
EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134 The following information will be used to determine the effectiveness of the
More informationOklahoma Department of Career and Technology Education
Oklahoma Department of Career and Technology Education Information Commons September 2016 Oklahoma Healthcare Practitioners and Technical Occupations Parameters Occupations Code Description 29-0000 Healthcare
More informationMILLERS COLLEGE OF NURSING
Congratulations on your decision to pursue your degree in nursing. The Millers College of Nursing offers a career pathway to meet the needs of individuals who are interested in obtaining the baccalaureate
More informationHIDD 101 HOSPITAL INPATIENT AND DISCHARGE DATA IN NEW MEXICO
HIDD 101 HOSPITAL INPATIENT AND DISCHARGE DATA IN NEW MEXICO Health Information System Act (24-14A-1, et seq. NMSA 1978) Provides authority for the Department of Health to collect health data. NMDOH had
More informationCPRS Application. Certified Peer Recovery Specialist. VCB CPRS Application Revised February
CPRS Application Certified Peer Recovery Specialist VCB CPRS Application Revised February 2017 - www.vacertboard.org - info@vacertboard.org 1 DIRECTIONS/CHECKLIST Documentation of high school diploma/ged
More information2016 Survey of Michigan Nurses
2016 Survey of Michigan Nurses Survey Summary Report November 15, 2016 Office of Nursing Policy Michigan Department of Health and Human Services Prepared by the Michigan Public Health Institute Table of
More informationUNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR)
1 OVERVIEW OF THE UNIVERSITY CITY FIRE & RESCUE DEPARTMENT (UCFR) University City Fire & Rescue Department Telephone: (514) 911-0129 1000 Rescue Drive University, IA 50436 City Demographics: The city has
More informationCapacity Building Grants: Education Contact Information
Capacity Building Grants: Education Contact Information Please remember to view the RFA and complete instructions on our website. Letter of Intent Due: February 14th, 2018, 5:00 PM ET Before the form is
More informationFamily Planning 2017 Claim Form
Family Planning 2017 Claim Form V 1. Family Planning Program: 1a. Full Pay Title X Partial Pay Only No Pay 2a. Billing Provider 2b. Billing Provider 3. Provider Name 4. Eligibility Date (V or ) (MM/DD/CCYY)
More informationPerinatal Research Consortium (PRC) Application for Participation
Perinatal Research Consortium (PRC) Application for Participation Date completed: / / Name of Institution: Principal Investigators (2): Instructions: Please complete every section. Use additional pages
More information2017 Claim Form 1. Choose one:
2017 Claim Form 1. Choose one: 1a. DFPP only: 2a. Billing Provider Family Planning Program: DSHS Family Planning Program (DFPP) PHC EPHC Partial Pay No Pay 2b. Billing provider 3. Provider Name 4. Eligibility
More informationDELTA STATE UNIVERSITY ROBERT E. SMITH SCHOOL OF NURSING RN TO BSN COMPLETION PROGRAM APPLICATION
RN TO BSN COMPLETION PROGRAM APPLICATION I am applying for the Fall of 20 Full-time Part-time 1. Name in Full (Last) (First) (Middle) 2. Home Address (Number & Street or RFD) (City) (State) (Zip) (County)
More informationEducation and Training
Cherriots accepts applications only for specific available positions. This application is valid only for the following position: (list specific position applied for) If offered position, length of time
More informationNurse Aide Training Program
Nurse Aide Training Program In this Nurse Aide Training Program students will learn about and experience caring for another human being, including bathing, showering, oral and denture care, feeding a person
More informationCOUNTY OF ALAMEDA GENERAL SERVICES AGENCY-PURCHASING DEPARTMENT. REQUEST FOR INTEREST #10145/AN/04 for RISK MANAGEMENT S ERGONOMIC LABORATORY SERVICES
COUNTY OF ALAMEDA GENERAL SERVICES AGENCY-PURCHASING DEPARTMENT REQUEST FOR INTEREST #10145/AN/04 for RISK MANAGEMENT S ERGONOMIC LABORATORY SERVICES NOTICE TO VENDORS REQUESTS FOR PROPOSAL (RFP) ISSUED
More informationCollege of Sequoias Associate Degree In Nursing Program Program Application Packet
The College of Sequoias Registered Nursing Program welcomes your application. This packet contains all application instructions and forms required for program application. This packet is available on-line
More informationExample Application DO NOT SUBMIT
Supervised Agricultural Experience (SAE) Grant Application Grant Information Amount: $1,000.00 Applicant Information Last Name First Name FFA ID Gender DOB Dues Paid Contact Information Address City State
More informationIf you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5.
If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5. Student Name of Birth Sex: Male Female Address Street City State Zip Grade Room
More information2018 State Funded Youth Employment Program
2018 State Funded Youth Employment Program APPLICATION OF INTEREST Completion of this application does not guarantee a slot in the program. This program is currently PENDING funding. Youth will be notified
More informationKaiser Permanente Youth Exploration Academy in Healthcare (KP YEAH!)
Kaiser Permanente Youth Exploration Academy in Healthcare (KP YEAH!) APPLICATION OVERVIEW KP Youth Exploration Academy in Healthcare (KP YEAH!) is a paid, 4 week-long, interactive exploration program for
More informationStandards for Success ROSS Data Elements
This shortcut assists ROSS Grantees to identify: Relevant data elements to collect; Questions for gathering information for the data element; and Possible response options. Participant Description 1 Person
More information2015 Physician Licensure Survey
2015 Physician Licensure Survey 1. What is your racial background? Please select all that apply. White American Indian or Alaska Native Native Hawaiian/Pacific Islander Black or African American Asian
More information2019 CTS/MNDOT CIVIL ENGINEERING INTERNSHIP PROGRAM APPLICATION
2019 CTS/MNDOT CIVIL ENGINEERING INTERNSHIP PROGRAM APPLICATION Name: Current address: Permanent address: Phone number: E-mail address: I am currently pursuing an undergraduate degree in civil engineering
More informationWelcome Baby Prenatal Intake
Outreach Specialist: Welcome Baby Prenatal Intake Date: / / Length of visit: hour(s) minute(s) Attempted call #1: (date) Attempted call #2: (date) Attempted call #3: (date) Client name: DOB: / / Home address:
More information2011 Melanoma Physician Quality Reporting (PQRS): FREQUENTLY ASKED QUESTIONS
Q: What is the Physician Quality Reporting System? A: The Physician Quality Reporting System, formerly known as PQRI, is a program developed by the Centers for Medicare and Medicaid Services (CMS) to provide
More informationREGISTRATION FORM (Minors)
LEGAL NAME REGISTRATION FORM (Minors) Social Security#: Date of Birth: Sex: M or F Nickname: Religion: Church: Race (circle one): White Black-Asian AM Indian Alaska Native Native Hawaiian Pacific Islander-Unknown
More informationThese documents contain the questions for the Illini Career and Internship Fair. At the University of Illinois at Urbana-Champaign
These documents contain the questions for the 2016 Illini Career and Internship Fair At the University of Illinois at Urbana-Champaign Questions are uploaded via CampusLabs and students fill out their
More informationAPPLICATION FOR EMPLOYMENT
APPLICATION FOR EMPLOYMENT 895 Mary Dunn Road, Hyannis, MA 02601 (508) 778.5040 Fax: (508) 778.9642 www.capeabilities.org Accredited by The Commission on Accreditation of Rehabilitation Facilities Thank
More informationDear Kaniksu Patient,
Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless
More informationRESPITE CARE VOUCHER PROGRAM
HELPING HANDS of VEGAS VALLEY 2320 Paseo Del Prado B-204, Las Vegas, NV 89102 (702) 507-1848 or Fax (702) 728-2963 cory.lutz@hhovv.org RESPITE CARE VOUCHER PROGRAM Dear Applicant: Thank you for your interest
More informationPatient Information Form
Patient Information Form Full Name: Date of Birth: / / Gender: M or F SS#: Marital Status: Single Married Widowed Divorced Employment Status: Employed Unemployed Retired Disabled Address: City: State:
More informationDivision of Peer-Based Services 9-Month Internship Program
Division of Peer-Based Services 9-Month Internship Program RAMS PEER INTERNSHIP PROGRAM 1282 MARKET STREET SAN FRANCISCO, CA, 94102 TELEPHONE : (415) 579-3021 FAX: (415) 941-7313 The RAMS Peer Internship
More information