Launch Closeout Form
Account Name
*
License Number
Launch Start Date
*
-
Month
-
Day
Year
Date
Number of Physical Locations Launched
*
Rep Name
*
First Name
Last Name
Rep Email
*
example@example.com
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Setup Confirmation
Describe the Current Inclusion Criteria
*
Attestation that All Setup is Completed
*
Installation/Bookmark of Software on Devices
Billing Templates in Place
Tablets Synced to WiFi
Usernames/Passwords Setup & Saved
Signs/Materials Positioned Around Clinic
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Workflow Description
Step 1: Screening
Screening Questionnaire Completed Where?
*
Please Select
Waiting Area/Front Desk
Exam Room
Other
Screening Questionnaire Format:
*
Please Select
Tablet
Paper
Other
Step 2: Physical Performance
Balance Tests Completed Where?
*
Please Select
Exam Room
Other
Balance Tests Completed by Who?
*
Please Select
MA Staff
Provider Staff
Other
Step 3: Intervention & Documentation
Note Template (Copy/Paste) Inserted into Note by:
*
Please Select
MA Staff
Provider
Other
Billing/Charge Completed by:
*
Please Select
MA Staff
Provider
Other
Step 4: Other
Anything Else Needed to Know about Workflow?
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Training
Front Desk
Front Desk Staff Members Trained (Names)
*
Front Desk Overall Acceptance of Program
*
1
2
3
4
5
MA Staff
MA Staff Members Trained (Names)
*
MA Staff Overall Acceptance of Program
*
1
2
3
4
5
Providers
Providers Trained (Names)
*
Providers Overall Acceptance of Program
*
1
2
3
4
5
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Portal Training & Closeout
Admin Trained at Closeout (Name)
*
Portal Closeout
*
Software Shortcut Saved on Admin's Computer
Portal Explained to Admin
Admin Demonstrates Access to Portal and All Features
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Additional Insight/Problems/Positives or Required Follow Ups from Launch
*
Overall Client Acceptance of Program and Launch
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
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