Hospital Operations Research Publication Consent Form
Please complete this form to provide your consent for the publication of hospital operations research findings.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital/Department Affiliation
*
Role in Research (e.g., Patient, Staff, Collaborator)
*
Please Select
Patient
Hospital Staff
Research Collaborator
Other
Title of Research Study
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Questions (optional)
Signature
*
Submit Consent
Submit Consent
Should be Empty: