Thank you for your interest in the Johns Hopkins Fall Risk Assessment Tool (JHFRAT).Please complete this brief form and a team member will be in touch with you promptly. Organization: * Organization Mailing Address Street * City * State * Zip Code * Country: * Point of Contact Organization Contact Person: * Contact Email Address: * Contact Phone Number: * Licensing Information License Type: * Which type of license are you purchasing? Acute Care License Home Health Care License Commercial In what format will the JHFRAT be used? * Paper Electronic Both Will the JHFRAT be used in your electronic medical record system? * Yes No What electronic medical record system does your organization use? * - Select -CernerEpiceClinicalWorksPractice FusionNext GenAdvancedMDAllscriptsPraxisAthenahealthMeditechGreenway HealthOther... What electronic medical record system does your organization use? Other... Number of facilities that will be using the JHFRAT: * Name of all facilities that will use the JHFRAT: * The name of each facility where the JHFRAT will be used is required. If other organizations would like to discuss the tool, may we give them your contact information? * Yes No JHFRAT Fall Risk Contract Terms Leave this field blank
