First Name:
Last Name:
Company:
Are you a subscriber to HealthLeaders Magazine? Yes No
Gender: Male Female
How did you find out about us? -- Please Choose One -- Direct Mail Word of Mouth Web Link Emailed by Friend Email Web Banner Business Card Other Newspaper Online news Trade Show Journal/Magazine Search Engine Other HealthLeaders Magazine
What segment of healthcare do you work in? -- Please Choose One -- Hospital Health System (IDS/IDN) Physician Org (IPA/MSO/PHO/Clinic) Health Plan/Insurer (HMO/PPO/MCO/PBM) Ancillary Provider (Home health, SNF, Lab, Rehab, LTC, Postacute, etc) Pharmacy/Pharmaceutical Employer/Purchaser Government Education/Academic Group Purchasing Org Consulting/Law/Financial Services Technology Products/Services Vendor/Supplier Trade Assn, Accrediting Body Media/Publishing/PR Other
What is your title? -- Please Choose One -- Chief Executive Officer President Administrator Executive Dir/Partner/Board Member Chief Operations Officer Chief Financial Officer Chief Information Officer Chief Technology Officer Chief Counsel Chief Compliance Officer Chief Medical Officer Chief of Staff Medical Director Physician Mgmt(MD), VP Medical Affairs Chief Purchasing Officer VP, Director, Dept. Head MD/Physician Pharmacist Nurse (NP/LPN/LVN/CNA/RN) Attorney/Consultant PhD/Professor Employee/Staff Other Assistant Administrator VP Operations/Administration VP Finance VP Technology/MIS/IT VP Compliance/Compliance Director Other Legal Counsel VP Marketing/Sales/Business Devlopment Dir/Dept Mgr Mktg/Sales/Business Dev Chief Nursing Officer VP Clinical Services Chief Medical Information Officer Principal Owner VP Clinical Informatics VP Clinical Quality VP Media Relations Director of Patient Safety Director of Quality Director of Safety VP of Nursing Director of Nursing
Which best classifies your place of employment by the number of beds? -- Please Choose One -- 1-199 200-499 500-999 1000+ n/a
Which best classifies your place of employment by the number of sites within your organization? -- Please Choose One -- 1-5 6-20 21-49 50+ n/a
Which best classifies your place of employment by the number of physicians? -- Please Choose One -- 1-2 3-9 10-25 26-49 50-99 100+ n/a
Which best classifies your place of employment by the number of enrollees? -- Please Choose One -- 1-49,999 50,000-99,999 100,000-249,999 250,000-499,999 500,000 n/a
