POWER INTENT TO ENROLL

Please complete and submit the online Enrollment Form or download and complete the PDF form below. Once your information is received, we will send your enrollment packet to the email provided.

 

Completed PDF forms can be emailed to power@cchmc.org.

In order to enroll, your site should meet the following criteria to participate in POWER. 

 

  • Our site provides multi-component weight management services for youth with obesity. Multi-component programs offer treatments that address nutrition, physical activity and behavioral strategies.

 

  • At our site data collected on demographics, clinical outcomes and visit characteristics for the patient population meet the required set of data elements for POWER as listed below.

 

  • Patient Characteristics:

    • Gender: Male, Female

    • Race: Black or African-American; American Indian/Alaska Native; Asian; Native Hawaiian/Pacific islander; white or Caucasian; Other; Unknown

    • Ethnicity: Hispanic, non-Hispanic, Unknown

    • Age at visit

    • Primary health insurance type: Medicaid, Private, self-pay, unknown

    • Zip code (1st 3 digits)

    • Anthropometric Data: Height, Body Weight

 

  • Visit Characteristics:

    • Visit Format:

      • Individual visit with a single provider

      • Individual visit with multiple providers

      • Group visit with a single provider

      • Group visit with multiple providers

    • Provider Type at Visit:

      • Medical (MD-DO, PA, NP)

      • Registered Dietitian

      • Exercise / Activity Specialist

      • Physical Therapist

      • Psychologist

      • Social Worker

      • Health Educator

      • Other healthcare provider (specify):  (Note: For example other medical provider from sub-specialties such as Endocrinology, Pulmonary, Cardiology, Gastroenterology,  Adolescent Medicine, Psychiatry; Nurse)

 

By completing the Intent to Enroll, your site commits to completing the following requirements once approved to enroll in POWER:

 

  • Identify staff at site to collect data and process it for submission to the POWER Data Coordinating Center.

 

  • Obtain IRB approval and informed consent/assent from new patient families to collect prospective clinical data

 

  • Submit fully executed POWER Data Coordination and Use Agreement

 

  • Submit $X,XXX enrollment fee to participate in Cycle 4 of the POWER project, which will cover participation from July 1, 2020 through June 30, 2022.

Enrollment Form

To begin your enrollment in POWER, please take the time to fill out the information below.  

CONTACT INFORMATION

SITE INFORMATION

PROGRAM INFORMATION

(check all that apply)

Clinic/Program Characteristics:
Clinic/Program Staff