ICN Data Request Form

ImproveCareNow Registry Request Form
Thank you for your interest in improving the ImproveCareNow Outcomes Registry! Please fill out the form below and submit it to info@improvecarenow.org. Our staff will review the form, share with the ICN Data Operations Committee, and follow up with you within two weeks regarding next steps and any relevant status updates.
Name:
Role:
Care Center/Organization:
Email:
example@example.com
Sponsor (if applicable):
Strategic Domain Impacted:

Other
- Data element(s) being requested:
- Is this needed to support a new measure?
- If yes, please provide additional details:
- Is This needed to support... ?
  
  Other
- Please provide additional details:
- Additional benefit to the network?
- What potential burden will this measure become in order to collect and report the data?
- How will this measure impact centers' QI initiatives?
- How will this measure impact centers' outcomes?
- Please attach any relevant materials for reference, if applicable:
  
  Cancelof
- Project Type:
  
  Other
- Project background and description:
- Please attach any relevant materials for reference, if applicable:
  
  Cancelof
- Data being requested:
- Project goal(s)/aim(s):
- Benefit to network:
- Collaborators:
  
  Other
- Registry enhancement(s) being requested:
- Benefit to network:
- Would this enhancement help you provide better care to patients?
- If yes, please provide additional details:
- Would this enhancement improve data accuracy?
- If yes, please provide additional details:
- Would this enhancement save youtime?
- If yes, please provide an estimate
- What potential burden will this enhancement become in order to collect and report the data?
- How will this enhancement impact centers’ QI initiatives?
- How will this enhancement impact centers’ outcomes?
- Please attach any relevant materials for reference, if applicable:
  
  Cancelof
- Should be Empty:

ImproveCareNow Registry Request Form