NJPBRN

JOIN

NJ PBRN ENROLLMENT FORM

Thank you for your interest in joining the New Jersey Practice- Based Research Network, an initiative led by the Rutgers Institute for Health, Health Care Policy and Aging Research. The mission of the Network is to improve population health and equity for all New Jerseyans through practice-centered research, education, and dialogue. Our goal is to facilitate a forum for continuous practice improvement for all NJ ambulatory care practices.

By enrolling, you will receive:

Curated alerts from our team when there are research and quality improvement projects that align with the priorities and needs of you and your patients
Access to our network of experts as well as resources that will make collaborating with other clinicians and researchers easier

Please complete this short form to join. There are no fees, and your information will not be re-distributed.

Note: * Parts are required.

If you prefer a PDF form, please click here to download the form and email to NJPBRN@ifh.rutgers.edu

ABOUT YOU

* Enrollment

I am enrolling myself

I am enrolling my practice

ABOUT YOUR PRACTICE

* Practice Name

* Address 1

Address 2

* City

* Zip Code

Hospital affiliations, if applicable (separate by comma)

* Practice type (check all that apply)

Private office
Federally Qualified Health Center (FQHC) or Look-Alike
Hospital-based clinic or outpatient department
Other health center/clinic (not hospital-based or FQHC)
Medical school/faculty practice plan
Other (specify)

* Specialties offered in your practice (check all that apply)

* Number of full-time equivalent physicians (MD, DO)

* Number of full-time equivalent staff

* Number of full-time equivalent Physician Assistants and Nurse Practitioners

* Approx. number of patients treated per year

* COMMUNICATING WITH YOU

Medical Director

* First name

* Last name

Credentials

Phone Number

* Email

Administrator

* First name

* Last name

Credentials

Phone Number

* Email

* Who should we contact with updates about the Network? (check all that apply)

Medical Director
Administrator
Other (list name, title, phone, and email)

* Tell us a little bit about your patient population. For example, do you have a high volume of Medicaid patients? Patients from a specific racial/ethnic group? Patients who have mostly elderly?

* Tell us some of your immediate needs that we can addressed through research

ADDITIONAL INFORMATION (OPTIONAL)

Do you expect to change EHR systems in the next 12 months?

Yes (list EHR system if known)

Not Sure

Has your practice ever participated in a research study or quality improvement project led by an external organization (e.g., university, department of health, payor)?

Yes, currently participating. Briefly describe most recent study/project:

Name of external organization

Study/project goals

Funding source (if known)

Yes, participated in the past. Briefly describe most recent study/project:

Name of external organization

Study/project goals

Funding source (if known)

Not Sure

CONFIRMATION

Membership obligations are minimal, and there are no fees.

By submitting this enrollment form, you agree that, to the best of your ability, you will do the following:

Complete an annual practice survey
Participate in relevant research projects and educational activities (incentives and CME/CEU credits may be available)
Attend at least one networking event per year

* Agree