Step 2: Fill out the form below and attach your two completed spreadsheets.

Name of Organization
State
Option of Versions NOSORH Performance Measures Tool- $3,000 Enhanced NOSORH Performance Measures Tool- $8,000
Structure of organization:
University based   Department of Health   Independent Non-profit  Other (please specify)
To maximize efficiency, please designate one person within your office to serve as the primary contact person. This person will serve as a liaison between staff members and the UND Center for Rural Health. Technical experience is not necessary however, your contact person should have a solid grasp of your organization's programs, a good working relationship with all users, and be a good communicator who is able to translate your organization's needs.
Primary Contact Person
Title
Email
Phone

Please attach the user template from step one.
	Attach file here
Please attach the organizations template from step one.
	Attach file here
Additional Information - please check box to consent.
	NOSORH Performance Measures Tool Your cost through NOSORH: $3000 per year. Sub-licensed (payable) through NOSORH. Data anonymously aggregated with other PCO users for NOSORH use.
Are you interested in on-site training? (Web-based training will be provided through NOSORH at no cost)
	On-site training- UND Center for Rural Health staff will provide up to one full day of on-site training. Cost: $500 plus travel from Grand Forks, ND to destination.