QIT Fellowship 2014
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QIT Room Request Form
American Heart Association for PCRC
2016 Patient Safety Fellowship
2016 Salk Fellowship
2017 JHF Summer Internship
& Licensed Practical Nurses
APPLICATION DUE DATE MAY23rd, 2014
A program of The Jewish Healthcare Foundation
Pittsburgh Regional Health Initiative
Centre City Tower /
650 Smithfield Street /
Pittsburgh, PA 15222
ABOUT THE PRACTICE
NAME OF PRACTICE
ADDRESS OF PRACTICE
PREFERRED EMAIL ADDRESS
1. Has your practice received Patient-Centered Medical Home (PCMH) recognition - level 1,2, or 3?
2. Is the practice participating in pay for performance programs (ie: Highmark Quality Blue, Gateway to Practitioner Excellence, or UPMC Health Plan Partners Program?)
3. YOUR ROLE IN THE PRACTICE:
4. Are you more interested in
I enjoy both equally
5. How do you believe the MA/LPN Champions program will benefit you? How might it benefit your practice?
6. What special healthcare experience, training, or certifications do you have?
7. Do you intend to pursue any additional education, training or certification? If so, please describe.
8. In your current role at your practice what do you find most satisfying and most challenging?
Please submit a letter of recommendation from your practice manager or supervisor who is able to highlight your skills, character, talents and career development interests.
Please have the recommendation letter sent to Dr. Bruce Block via email to
or fax to 412-586-6701 by
Centre City Tower, Suite 2600
650 Smithfield Street
Phone: (412) 594-2550
Fax: (412) 232-6240
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