CHAMPS Enrollment Form:

Yes, I wish to enroll the air medical provider program listed below in the CHAMPS Service as a ...
Basic subscriber at a cost of $500

This fee includes one administration of the online survey tool as well as one report of the results of the cultural evaluation for your organization. The report will provide the aggregate ratings for all respondents in your organization in accordance with the eight cultural areas that form the survey.

The report will also include a separate breakdown of the responses in those areas for each functional domain within your organization. Functional domains include Pilots, Medical Crewmembers, Maintenance Technicians, Communications Specialists / Operational Controllers, and Management. For air medical providers who wish to compare these cultural markers between different bases or regions under their management, base comparison reports can be ordered for $150 per each additional base or region.

 
Premium Supporter$1,000

In order to promote the initiation of the CHAMPS survey tool as an industry-wide benchmark of the health of an organization’s safety culture, NEMSPA is offering optional distinct Premium Supporter benefits to all air medical provider organizations that subscribe to CHAMPS at an additional $500 fee, i.e. for a total of $1,000.

Premium Supporters will receive up to 5 additional inter-base comparison reports (i.e. a total of 6 bases compared) at no cost (a $750 value).

 
Number of participating programs so far:

24 and counting...
  [Bold fields are mandatory]

Salutation:
First Name:
Last Name:
  
Organization:
Position:
  
Org. Address:
City:
State:
ZIP:
Country:
  
Email:
  
Work Phone:
Cell Phone:
Fax:
 

In addition to enrolling as CHAMPS survey participants, we also wish to be recognized as an EDP Project Sponsor with an additional contribution of:
U.S. $   ($500 minimum)
EDP Project Sponsors will enjoy the benefit of having their names listed on the appropriate EDP materials.

(Please note that you will not be held responsible for this commitment before a minimum combined pledge of $50,000 has been reached.)
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