FORM PREVIEW PAGE

Thank you for your interest in joining the National Hypertension Control Roundtable (HTN Roundtable).

HTN Roundtable Member Application

Please answer the following short questionnaire so we can learn more about your organization and why your organization is interested in joining the HTN Roundtable. We will send you a confirmation email within one to two weeks after your submission.

Thank you for your interest and your efforts to improve hypertension control rates.

THIS FORM FOR TESTING ONLY

Membership Questionnaire

Membership form replicated from SmartSheet 05/15/2024

About Your Organization

In this section, you will provide information related to your organization.
Please type the name of your organization that is interested in becoming a member of the National Hypertension Control Roundtable.
Which sector(s) best describe your organization?(Required)
Please select the sector(s) that describe your organization. You can choose more than one.
In this section, please succinctly describe what your organization is presently doing to address hypertension.
Are you or someone within your organization interested in taking on a leadership role within the Roundtable (i.e., join the Steering Committee, participate on a Task Group etc.)?(Required)
Please indicate if you or someone else within your organization may be interested in serving in a leadership role. Please note, there are limited leadership positions available.

Organizational Contact Person

In this section, you will provide information related to who will serve as the primary contact person for your organization.
Please type your first name, last name, and any credentials. Credential examples include MBA, MPH, MD, etc.
Please type your current title at your organization
Please type your email address.
Please type the best telephone number, in case we need to contact you.
The National Hypertension Control Roundtable website is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $300,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.