CISQ Measurement Instrument Request Form

Instructions:

1.  The Measurement Instrument Request Form is available for download in PDF format only.  You will need  Adobe® Acrobat® Reader® to download and print the form.

2.  Click on this link :   CISQ Measurement Instrument Request Form

3.  The form will open in Adobe® Acrobat® Reader® .

4.  Print the form.

5.  Please review the form carefully and sign it where indicated.  Feel free to contact Dr. Gugerty by email or phone (410-706-4918) if you have any questions regarding the form.

6.  Return the completed form via fax or US Mail to:

        Dr. Brian Gugerty

        University of Maryland at Baltimore

        655 West Lombard Street, Room 455D

        Baltimore  MD  21201

        fax: 410-706-3289

7.  Brian Gugerty will receive the form and review the request. 

8.  If your request is approved by the research team, Dr. Gugerty will contact you via email with information on how to complete the next step of the instrument release, which is completion of the online Site Form.

9.  The Site Form is an information gathering tool that is divided into 10 sections.  The purpose of the Site Form is to collect contact information as well as information about the site, system implemented, implementation process used and training process. 

   Here are 2 sample questions from the Site Form:

   1.  What type of healthcare information system is being/was implemented?

   2.  When did training occur in relation to the go-live date?

10.  Dr. Gugerty will release the measurement instrument requested after receipt of the completed Site Form. 

**After the instrument is released by Dr. Gugerty, it can be used for research purposes as outlined and agreed upon in the aforementioned Request Form.  Please remember to follow through with the submission of de-identified data (as noted in #4 on the Request Form) so that the measurement instruments may be continually validated for future use.

Thank you for your interest in the CISQ Family of Measurement Instruments!