Integration of Newborn Screening

Print and Fax to 202-728-9469, Attn: Martrell Kelly

"Integration of Newborn Screening & Genetic Service Systems
with Other Maternal and Child Health Systems"

The registration deadline for this conference is Friday, September 19th .

Registration Form

Required fields are indicated with asterisks (*) (if you do not have any information to enter into a required field, just type "NA"). Please check to make sure that your e-mail address is entered correctly. When complete, please fax to (202) 728-9469, Attn: Martrell Kelly; or call Health Systems Research at (202) 828-5100.

Your Contact Information:

I am registering as a (circle one):*

Participant

Presenter

First Name*

Middle Initial

Last Name*

Academic Degrees *

Job Title*

Department

Division

Organization*

Address*

City*

State*

Country

Zip Code*

Telephone*

Fax*

E-Mail*

Special Needs/Accommodations:

Which on-site lunches will you be participating in?*

	Wednesday, October 15th only. (*Registration fee will be $12)
	Thursday, October 16th only. (*Registration fee will be $12)
	Both Wednesday and Thursday. (*Registration fee will be $24)
	I will not be participating in either on-site lunch. (No registration fee will be required)

* Note: This registration payment is NOT required for:

1- individuals registering as presenters.
2- participants whose expenses are not covered by their State grant (which are already being covered by us, the logistical contractor).
3- participants who do not wish to participate in the on-site lunches.

Hotel Reservations:*

	Yes, please make me a room reservation for the night of Tuesday, October 14th.
	Yes, please make me a room reservation for the night of Wednesday, October 15th.
	Yes, please make me a room reservation for both Tuesday, October 14th and Wednesday, October 15th.
	No, I will not need hotel accommodations. I will make my own arrangements.

How is your participation in this meeting being funded?*

	My State Grant
	The Logistical Contractor for this meeting

Which roundtable session topics would you prefer to participate in?:*

Breakout session #1, Day 1: (please check one)

1 - Leadership, Project Governance, and Evaluation
2 - Project Management, Stakeholder Involvement, and Evaluation
3 - Organizational/Technical Strategy and Evaluation

Breakout session #2, Day 1: (please check one)

1 - Technical Support and Coordination, and Evaluation
2 - Financial Support and Management, Policy Support, and Evaluation

Breakout session #3, Day 2: (please check one)

1 - Introduction and Overview of Framework
2 - Developing Indicators for Framework

Please answer the following questions to help us better prepare for the meeting:

How would you describe yourself?* (circle one)

Consumer/Family	Information Systems	Newborn Hearing Screening	Legislator
State Genetics Coordinator	MCH or MCH/CSHCN Director (Title V)	Epidemiologist	Program Evaluation
Newborn Dried Blood Screening - follow-up	Clinician - Medical Home	Statistician	Other
Newborn Dried Blood Screening - laboratory	Clinician - sub-specialty	Insurance Payor

Circle either yes or no for each question
In this capacity, are you a State Employee/Contractor?*	YES / NO
In this capacity, are you community-based?*	YES / NO
Are you a member of your State's Newborn Screening/Genetics Advisory Committee?*	YES / NO
Are you a member of a community-based organization that has a partnership with the State's health department?*	YES / NO

BILLING INFORMATION

I will be paying by: (circle one)

CHECK

CREDIT CARD

Payment Amount: (circle one)

$12.00

$24.00

Name as shown on card:

Billing Address (if different than above)

City, State, Zip

Credit Card Type*

Credit Card Number*

Credit Card Expiration (mm/yy)*

*please make checks payable to HSR, Inc.