1. Name of the hospital/institution/group:

2. Location: City State Alaska Alabama Alberta Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico Newfoundland New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

3. Description of team:
(full-time, part-time, moonlighters, availability of consultation, etc.)

4. Involved in educating residents/medical school students? Please describe:
(residents [PL1,2,3], nurse practitioner students, etc.)

5. Wards/areas covered:
NICU
PICU
ER
Urgent Care
Newborns/Pediatric floor
Other

6. Primary contact:
Name
E-mail
Phone

7. Submitted by:
Name
E-mail