* 1. Name (First and last)

* 2. Phone

* 3. Email

* 4. What zip code do you live in?

* 5. Have you had more than 1 year experience in any of the following areas? (Check all that apply)

* 6. Do you currently have any of the following credentials? (Check all that apply)

* 7. Have you ever participated in preparing for an inspection by the Joint Commission or the state health department?

* 8. Have you ever conducted an audit or an inspection of healthcare facilities?

* 9. Have you ever provided consultation or training pertaining to the improvement of healthcare quality?

* 10. Have you ever served as an instructor for a continuing education (CE) or certification course for healthcare professionals?

* 11. Would you like to be contacted about performing audits or conducting education around endoscope reprocessing practices?

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