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| 1. |
Salutation |
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Please provide your contact information
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| 3. |
Role for Canadian Patient Safety Week
* Please specify
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| 4. |
Position(i.e. role with your organization) |
| 5. |
Organization |
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| 6. |
If Applicable:The following information will help us as we plan for Canadian Patient Safety Week. |
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Canadian Patient Safety Week Material will be sent to the mailing address provided below
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| 7. |
Mailing Address |
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City |
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Province/Territory |
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Postal Code |
| 11. |
Telephone |
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CPSI typically provides CPSW participants with materials to distribute to your site or organization. If CPSI were to provide you with a package of materials, please indicate the size and type of package you would require.
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| 12. |
Package Size |
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Package Type |
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Should mailouts of promotional or marketing materials be sent to you?Please note: If you are part of a committee for your site or organization, please nominate one person per site to receive materials. |
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CPSI also sends out a monthly CPSI & SHN newsletter, as well as information about initiatives, programs and events as it happens. To help stay informed, please select the mailings you would like to receive:Select from 1 to 5 options |
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All information will be kept strictly confidential and will be used by the Canadian Patient Safety Institute solely for the purposes of assisting and informing our CPSW Leaders.
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