An example data collection form to be completed by new providers wishing to enroll in a Practice-based Research Network (PBRN). A network can use this information to describe its network membership and help connect potential collaborators. Click here to download.
Courtesy of the American Academy of Family Physicians AAFP National Research Network's (AAFP NRN) Collaborative Care Research Network (CCRN).  http://www.aafp.org/online/en/home/clinical/research/natnet/ccrn.html