Hospital Department Coordination Application Form
Submit your application to coordinate with other hospital departments for joint projects or initiatives.
Primary Department Name
*
Contact Person (Primary Department)
*
First Name
Last Name
Email Address (Primary Department Contact)
*
example@example.com
Phone Number (Primary Department Contact)
Please enter a valid phone number.
Format: (000) 000-0000.
Collaborating Department(s)
*
Contact Person (Collaborating Department)
First Name
Last Name
Title of Project/Initiative
*
Brief Description of the Project/Initiative
*
Objectives of the Coordination
*
Expected Outcomes
Proposed Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Proposed End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Resources or Support Needed from Collaborating Department(s)
List of Key Staff Involved (Names & Roles)
Approval from Department Head (Primary Department)
*
Yes, approved
Pending approval
Additional Comments or Notes
Submit Application
Should be Empty: