NW5 Engage Post - Assessment

By answering each question below, you acknowledge

Your facility has received notification about being enrolled in the Network's 2020 BSI QIA.

All facility personnel are current and have been updated in CROWNWeb.

This QIA will be included as part of the monthly QAPI meetings; the Network reserves the right to review minutes regarding the action plan at any time.

The above-listed facility is responsible for notifying the Network of any and all changes to your facility's QIA project lead.

Please identify below, the person who will be your facility's lead contact for this QIA

QIA Lead's First Name:

QIA Lead's Last Name:

QIA Lead's Email:

Form Completed By

First Name:

Last Name:

Email:

NW5 BSI Project Acknowledgement

Facility Information

By answering each question below, you acknowledge

Please identify below, the person who will be your facility's lead contact for this QIA

Form Completed By

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