Tourette Chapter Outreach PRL

OFFICAL SITE TOURETTE SYNDROME ASSOCIATION INC

TSA CHAPTER PRL OUTREACH
Tourette Syndrome Association, Inc.

The PRL Outreach program, as discussed at 2006 Leadership Training, is being sponsored by the TSA/CDC partnership; a form needs to be filled out for each physician approached. Physician information will be compiled to provide REQUIRED program progress reports to the CDC.

Please fill in the information below. Thank You!

Date of Initial Contact
Name of Physician:
Specialty:
Name of Practice:
Address:
City:
State:
Zip (or Postal code):
Phone: (include area code/extension)
Email Address:
Initial Contact:	in person telephone email mail
Person Contacted:	physician nurse receptionist other
Delivery of CD/DVD and HBO DVD	in person mail/UPS/other delivery service
Date of Delivery:
Date of confirmation of receipt:
Date of viewing:
Viewed by:	physician nurse receptionist other
Short summary reaction to viewing:
Date of follow-up call after viewing:
Results: Do you think this physician should be included in the PRL?:	yes no
Did the physician agree to be included in the PRL?	yes no
Submitted by:	TSA Chapter
Date of this Submission:
Name/title of person completing this form:
Your email address:

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TSA CHAPTER PRL OUTREACH Tourette Syndrome Association, Inc.

TSA CHAPTER PRL OUTREACH
Tourette Syndrome Association, Inc.