Pediatric Colorectal and Pelvic Learning Consortium Application for Membership

Name of Institution

Institution Address

Responsible PI

Email Address

Number of unique ARM patients seen in your clinic each year for the past 2 years:

Number of unique HD patients seen in your clinic each year for the past 2 years:

Number of new/redo cases seen per year regarding any aspects of colorectal and pelvic reconstruction (surgery, radiology, psychology, follow-ups, etc.)?

Do you have or refer to a Pediatric Surgery Service?

Are you able to commit to the minimum attendance standards for all consortium meetings? (Attend at least 1 of the 2 in-person Steering Committee meetings and a minimum of 50% of the PI/RC monthly calls each year) Are you able to commit to the minimum attendance standards for all consortium meetings? (Attend at least 1 of the 2 in-person Steering Committee meetings and a minimum of 50% of the PI/RC monthly calls each year) Yes No

Do you have a designated research coordinator or data entry person that can be supported at 0.4-0.5% FTE for the consortium? Do you have a designated research coordinator or data entry person that can be supported at 0.4-0.5% FTE for the consortium? Yes No