Form 1 Pharmacy SOPS Registration Form

ATTACHMENT A

Pharmacy Registration Page

*Email:

*

*Organization Name:

*

*First Name:

*

*Last Name:

*

Title/Position:

*Address 1:

*

Address 2:

*City:

*

*State:

*

*Zip Code:

* *

*Telephone number:

( )* * * * - * * Ext.: *

Fax number: ( ) * * - *

* 1. Which of the following do you represent?

Pharmacy/Pharmacy System

Quality Improvement Organization (QIO)

An organization or vendor submitting data on behalf of a pharmacy or pharmacy system

Another type of organization (please specify)

*

* 2. Will you have completed survey data collection and be able to submit your final electronic data file by November 1, 2014?

Yes No

* 3. How many pharmacies will you be submitting for? *

* 4. Did you make any changes to the AHRQ Pharmacy SOPS Questionnaire?

Yes

No