PSQH e-Newsletter Form

PSQH now offers you a way of staying up-to-date with most important information and product news relating to the entire arena of patient safety and quality healthcare issues. Please fillout and submit the form below to receive the PSQH e-Newsletter for free.

Your Mailing Address (*denotes required fields)
First Name: *
Last Name: *
Organization: *
Address: *
Address:
(2nd line, if necessary)
City: *
State/Province: *
ZIP Code/Postal Code: *
Your Phone, Fax and E-mail Address
Business Phone: *
Business Fax: *
E-mail Address: *
Confirm E-mail Address: *
Enter keycode here
(if applicable):
Your Job Description
Please Give Your Full Title: *
Click the button that best describes your title and involvement in patient safety (check only one):

(a) Chief Administrator, CEO, Chief Medical Officer, Chief Nursing Officer

(b) Medical Affairs Director, Pharmacy Director, Patient Services Director, Director of Patient Safety and Quality, Director of Administration, Manager

(c) Infection Control Officer, Patient Safety Officer, Risk Management Officer, Compliance Officer

(d) Physician, Nurse, Pharmacist, Diagnostic Technician, Therapist

(t) other (please specify):

Your Organization Description

Click the button that best describes your facility/organization (check only one):
(01) Hospital (500 beds or more)
(02) Hospital (201 - 499 beds)
(03) Hospital (200 beds or less)
(04) Multi-hospital System
(05) Group Practice
(06) Home Healthcare Organization
(07) Ambulatory Care Center
(08) Rehabilitation / LTC Facility
(09) Managed Care Facility (HMO, PPO, IPA, PHO, other)
(10) Insurer
(11) Federal Agency / Military
(12) Pharmacy
(13) Healthcare Consulting Company
(14) Pharmaceutical / Medical Equipment Company
(20) other (please specify):

How many employees are in your organization?
Over 500
201 - 500
51 - 200
10 - 50
Under 10

Please indicate the day of the month you were born (e.g. 1, 2, 3, or 31) *
(for verification purpose only)