ATTACHMENT 3a
Million Hearts™ Hypertension Control Champion Nomination
Form Approved
OMB No. 0920-xxxx
Million Hearts™ Hypertension Control Champion Nomination
Public reporting burden of this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.
Nominee: _________________________________________________________
Contact information (for individual submitting the nomination):
Name: ________________________________________________________________________
Address: _______________________________________________________________________
Phone: ________________________ E-mail: _______________________________________
Nominee information:
Name: ________________________________________________________________________
Business Address: ______________________________________________________________
Business Phone: _________________ Business E-mail: ____________________________
Check the box which best represents the nominee:
A healthcare system
A primary care practice/clinician
An obstetrics/gynecology practice/clinician
A family practice/clinician
An internal medicine practice/clinician
An osteopathic practice/clinician
A cardiovascular care practice/clinician
Other ________________________
Nominee Reach and impact
Number of patients enrolled in your practice or health system: _____________________
Number of patients seen at least annually: ______________________________________
Number of adult patients (18 – 85 years old) seen at least annually: ______________________
Describe patient demographics that support the practice or health system’s care for a challenging population:
Geographic region served __________________________________________________
Is this urban, rural, or both? __________________________________________
Percent of patients who belong to a racial/ethnic minority________________________
Percent of patients whose primary language is not English ________________________
Percent of patients who are eligible for Medicaid________________________________
Other ___________________________________________________________________
CDC defines “hypertension control” as a blood pressure reading < 140 mmHg systolic and <90 mmHg diastolic among hypertensive patients. There is no allowance for individuals on two or more medications.
How many adult patients in the total patient population seen annually are diagnosed with hypertension? ________________
Million Hearts™ supports use of the National Quality Forum #0018 or other nationally recognized measures for defining hypertension control (if other, please specify the measure used_________).
What is the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population? __________________ Date collected ________________.
What was the Hypertension Control Rate for the practice or healthcare system’s adult hypertensive population a year or more previous? ______________ Date collected: ___________
Do you report hypertension control rate to any other federal or regulatory agency?
Please
describe:
______________________________________________________________
___________________________________________________________________________
Is there
anything else you would like to add to support the
nomination?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Agreement to Participate
Please enter your name below to indicate that you, as the nominee, agree to the following.
If you are not the nominee, please enter your name below assuring that you have consulted with the nominee, and the nominee agrees to the following:
All information provided is true and accurate to the best of your knowledge. .
To participate in a data verification process if selected as a champion.
Consent to a background check if selected as a champion.
To be recognized by provider or practice name and location if selected, to participate in recognition activities, and to share best practices for the development of publically available resources.
To assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from my participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.
To indemnify the Federal Government against third party claims for damages arising from or related to competition activities.”
______________________________________________
Thank you for participating.
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |