Participation Form

University or State Agency Name *

Contact Information

Name *

Title

Department

Email *

Phone

(987) 555-4321

Are you currently engaged in a university-state partnership? - None -YesNo

Click here if you are with a university/academic medical center.

Complete if you are a participating university

State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

State Agency Partner

Area(s) of Expertise Clinical Care CoordinationClinical ResearchCost Avoidance/Cost SavingsData AnalyticsData ManagementFiscal and/or Program AdministrationHealth Care AdministrationHealth Care ReformHealth Policy Consulting and/or DevelopmentHealth Policy ResearchLaboratory ServicesMaternal/Child HealthOutreach and EducationPharmacy ServicesProgram Consulting and/or EvaluationProgram Development and/or ManagementQuality ImprovementTranslational ResearchWorkforce Development and TrainingOther

Current Services

Proposed Services

Projects

Click here if you are with a state agency.

Complete if you are a participating state

State Agency Name

University Partner

Current Projects

Area(s) of Interest Clinical Care CoordinationClinical ResearchCost Avoidance/Cost SavingsData AnalyticsData ManagementFiscal and/or Program AdministrationHealth Care AdministrationHealth Care ReformHealth Policy Consulting and/or DevelopmentHealth Policy ResearchLaboratory ServicesMaternal/Child HealthOutreach and EducationPharmacy ServicesProgram Consulting and/or EvaluationProgram Development and/or ManagementQuality ImprovementTranslational ResearchWorkforce Development and TrainingOther

How has this partnership benefited your state?

How can universities best respond to state needs?

Can we contact you? * - Select -YesNo

Additional Comments

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