1 2 3 4 Project Involvement Participation: Indicate the beginning and ending date (month & year) of your participation in the QI effort. Start Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Participation: Indicate the beginning and ending date (month & year) of your participation in the QI effort. End Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Improvement Cycles: Indicate how many improvement cycles you participated in. Participation in at least two full cycles is required. 2 3 4 or more Meaningful Participation: Please select which activities describe your participation in the QI effort. Must participate in at least 3 of the 4 activities for approval. (a) Project Design (b) Implementation of Interventions (c) Data Collection/Analysis (d) Meeting Participation Aim: What is the specific aim of the QI effort? Data Source and Collection: What was the source of the data used to measure performance in the QI effort and what were the methods for data collection? Were appropriate measurements identitified? Yes No Describe: Were you actively involved in the analysis of the collected data? Yes No Measures: Did the measures used address important issues for your patients? Improvement: Was the QI effort succcessful in improving care for your patients? If not, please explain why. Did you receieve guidance on appropriate parameters for applying intervention(s)? Role: Indicate your role in the QI effort. Activity: Describe your activity in the QI effort. Team Involvement: Were other members of your care team involved in the QI effort? If so, explain how. Leave this field blank
