Registration

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First Name

Last Name

Hospital/Organization/Business Address

Hospital/Organization/Business Address 2

City

State

Zip Code

Phone Number

Email Address

No: Participant(s) Required

Credentials

Your Position

Time in current role

Is your hospital a Critical Access Hospital (CAH), Rural Hospital or Prospective Payment System (PPS) Hospital?

CAHRural (<50 beds)PPS

Is your hospital accredited?

Yes, by The Joint CommissionYes, by The Joint CommissionYes, by Other... No

Please name source if you chose "other"

Please indicate your primary areas of responsibility

List area of responsibility if you chose "other"

Select your choice(s) of Wisconsin Quality Residency Program Modules ($250.00 each)

MODULE 9 (02/12/25) PERFORMANCE IMPROVEMENT & PROJECT FACILITATION | Virtual (+$250.00)

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