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. Contact Information Name * Email Address * Phone Number * Information Use Type * Acute Care Home Health Commercial Student Project Research Study Organization Information Organization Name * Street * City * State * Zip Code * Country * In what format will the JHFRAT be used? * Paper Electronic Will the JHFRAT be used in your electronic medical record system? * Yes No What electronic medical record platform will you be using? * How many facilities will be using the JHFRAT * Name of all facilities that will use the JHFRAT * Each facility must be listed below. JHFRAT Fall Risk Contract Terms 1-25.docx School Information Name of School * Name of Organization/Facility (i.e., hospital) where Tool will be used * Title of Your Project * Purpose of your project * Describe how the JHFRAT will be used in your project. Time Frame (school semester or anticipated number of months used) * JHFRAT Student Use - Contract Terms 1-25.docx Note: We will review the information provided and let you know if you have been approved to use the JHFRAT shortly. You may not use the tool until you receive approval. Study Information Name of the Study * Purpose of the study * List off all locations where the Tool will be used for the study * Is this research funded? * Yes No JHFRAT_Terms and Conditions_Study for Licensed Practitioner 10-24.docx We will review the information provided and let you know if you have been approved to use the JHFRAT shortly. You may not use the tool until you receive approval. Leave this field blank Math question * Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. 4 + 10 =
