Duke Clinical Research Institute / IDENTIFIED BELOW MAY DIFFER FROM THOSE OF THE HOSPITAL / S SURGICAL OUTCOMES ANALYSIS WILL BE LISTED WITH EACH HOSPITAL / /
IndustryTerm
electronic media / /
Organization
Name** Hospital Representative Title Hospital / Consumers Union of United States / Society of Thoracic Surgeons National Database Congenital Heart Surgery Database On behalf of / Society of Thoracic Surgeons / Duke Clinical Research Institute / HOSPITAL ON THE STS WEBSITE / Hospital NPI# Hospital Website Address/Hyperlink Hospital Representative Name** Hospital Representative Title Hospital / / /
Position
Signature Date Official / Name* Surgeon / combined Surgeon / CT surgeon / Representative / Surgeon / single surgeon / ADDITIONAL SURGEON / STS National Database Surgeon / CONGENITAL PUBLIC REPORTING SELECTION Surgeon / relevant Surgeon / No Yes No Surgeon / /
PUBLIC REPORTING DATA SHARING/CONSENT FORM The Society of Thoracic Surgeons National Database Congenital Heart Surgery Database On behalf of the STS National Database Surgeon Participant and the hospital identified below