Healthcare Collaborative Project Proposal

"*" indicates required fields

Personal Information

Salutation

First Name *

Last Name *

Credentials

Title *

Email *

Phone *

Mobile

Fax

Organization Information

Organization Name *

Organization Street Address

Organization City

Organization State/Province

Organization Zip/Postal Code

Project Information

Project Title *

Proposed Project Overview

Brief description of needs for data and intent of the project *

Match with Mission

Brief description of how the proposed project supports the NHC mission *

Data and Timeline

a. Identify if the request is a de-identified or limited data set *

b. Timeline for expectation of receipt of data *

Acknowledgement *

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.

Participant Resources

Company Resources

HIT Board

CMS QE Reports

QCDR Reports