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Healthcare Collaborative Project Proposal
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Personal Information
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First Name
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Last Name
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Credentials
Title
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Email
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Phone
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Organization Information
Organization Name
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Organization Street Address
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Project Information
Project Title
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Proposed Project Overview
Brief description of needs for data and intent of the project
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Match with Mission
Brief description of how the proposed project supports the NHC mission
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Data and Timeline
a. Identify if the request is a de-identified or limited data set
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Required
b. Timeline for expectation of receipt of data
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Required
Acknowledgement
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You are strongly encouraged to contact the Collaborative to discuss questions about fit or scope prior to submitting a Collaborative Project Request Form. Once a Collaborative Project Request Form is submitted, a team member will review and determine the following: 1. Match with mission, 2. Project viability, 3. Project appropriateness, 4. Reasonable timeline, and 5. Project category. If upon review, questions arise, staff of the NHC may reach out for further clarification on the project request.
I acknowledge that I have read and understand the
project submission requirements
and that this submission complies with those requirements.