Pre-Participation FM Residency Program or Family Practice Eligibility Questionnaire

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* 1. Name of Family Medicine Residency Program or Family Practice Clinic

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* 2. Name of Clinic Director

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* 3. Name of QI Project Contact

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* 4. Title and Credentials of QI Project Contact

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* 5. QI Project Contact Address

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* 6. QI Project Contact Phone Number

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* 8. Program geographic region

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* 9. Estimated Number of Female Patients Ages 18 to 44 years seen monthly by clinic.

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* 10. Please estimate how many family physicians will participate in this QI Pilot Project.

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* 11. Please estimate how many family physician residents will participate in this QI Pilot Project.

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* 12. Name of clinic EMR system.

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* 13. Is your clinic currently administering a HBC screening questionnaire?

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* 14. Is your clinic willing to implement a process and workflow to administer a HBC screening tool with young female patients seen at your clinic? Note: The project can support you in this activity.

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* 15. Can you commit to having your family medicine clinic participate in this HBC QI project as described in the project recruitment materials, to be launched in December 2023 through July 2024?

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