Clinical Audit 2016/17 Registration Form

Instructions

Please complete and return this form to participate in any of the RCEM 2016/17clinical audits as soon as possible.This form mustbe accompanied bya copy of the purchase order for the correct fee. Upon receipt of this form, RCEM will issue an invoice for payment within 30 days.

Completed registration forms should be returned to .

Emergency Department registration details

Please provide details for each Emergency Department (ED) within your organisation that will be participating in the RCEM clinical audits for 2016/17. Each organisation is asked to provide:

  • a clinical lead contact (i.e. the Consultant responsible for ED audits)
  • a lead administrative contact responsible for ED audits
  • an alternative administrative contact

ED 1 / ED 2 / ED 3
Trust name
Hospital name
Name of clinical lead for ED audits
Email address
Phone
Name of lead administrator for ED audits
Email address
Phone
Additional admin contact name
Email address
Phone
Registration details - Please tick the audits in which the ED(s) will participate
Asthma / ☐ / ☐ / ☐
Consultant sign-off / ☐ / ☐ / ☐
Severe sepsis and septic shock / ☐ / ☐ / ☐
Does your finance department accept invoices by email? / ☐Yes ☐No ☐Don’t know

Please note: RCEM is committed to openness and transparency. Published aggregate data for each participating ED will be available in the public domain after report publication.

P.T.O.

Payment details

Fees for participation in 2016/17 audits are charged according to the total number of audits your organisation has registered for using the following scale.

Total number of audit registrations for all sites (across organisation) / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
Total fee (inclusive of VAT) / £400 / £750 / £1,100 / £1,400 / £1,650 / £1,900 / £2,100 / £2,300 / £2,500

Example fees:

1 ED participating in all 3 audits = £1100 inclusive of VAT

2 EDs participating in 3 audits betweenthem = £1100 inclusive of VAT

2 EDs both participating in all 3 audits = £1900 inclusive of VAT

If you have any queries regarding registration, please contact the Quality Team through .