Thank you for your interest in Midwest Regional CAC's Peer Review Program.

This program runs from January 1st through December 31st of each year, and the cost to participate is $150 per center per year. It is the expectation that your center will participate in this program for the entire year and that your site will participate in your selected session/core community except for extenuating circumstances to ensure enough sites and fruitful conversation during peer review.

Please fill out the registration form on the following screens and pay the registration fee following the instructions at the end of this form. For tips to guide you through the registration process, visit bit.ly/24PRRoll.

If you have any questions about the application, please contact Maggie Larson, Peer Review Program Coordinator, at maggie.larson@childrensmn.org or 612-730-2299.

CampaignCaseSafeID

Verification

Please verify that this information is correct for your organization and make changes, if needed.

Organization Information

Full Organization Name

City

US State/Territory or Canadian Province

Primary Contact

Who will be the primary contact from your organization regarding peer review?

The primary contact is the main point of contact regarding your organization's participation in peer review. The primary contact is responsible for forwarding all links and other communication to team members.

Peer Review Contact Information

First Name

Last Name

Title

Email Address

Phone number

Please select the type(s) of peer review your CAC is interested in participating in:

Medical Peer Review

SANE Peer Review

Forensic Interview Peer Review

Spanish Speaking Forensic Interview Peer Review

Forensic Interview Peer Review: Interviewing Individuals with Disabilities

Medical Peer Review

Medical Peer Review Session Selection

Medical Peer Review will take place on the days/times listed below:

First Wednesday of the month 1-2 pm Central
First Thursday of the month 1-2 pm Central
Third Wednesday of the month 1-2 pm Central
Third Friday of the month 9-10 am Central

Your site will need to choose one of these times to attend on a consistent basis.

Each site will be required to present on a rotating basis, typically 3 times a year.

If you agree to the conditions above, please indicate a first and second choice for the Medical Peer Review sessions in which you wish to participate.

First Choice

Second Choice

Primary Contact

At the beginning of this registration process, you listed this person as your organization's primary contact for peer review:

Would you like someone different to be the primary contact for Medical Peer Review?

YesNoAs a reminder, the primary contact is responsible for forwarding all links and other communication to team members.

Medical Peer Review Primary Contact

First Name

Last Name

Title

Email Address

Phone number

Medical Peer Review

Medical Peer Review Participants

Please list the names and email addresses of any/all medical providers who will be participating in Medical Peer Review with your site in the coming year.

First Name	Last Name	Email Address

Comments

SANE Peer Review

SANE Peer Review Session Selection

SANE Peer Review will take place on the days/times listed below.

Your site will need to choose one of these times to attend on a consistent basis.

Each site will be required to present 2-3 times during the annual cycle.

If you agree to the conditions above, please indicate your day/time preference.

Second Wednesday of the month 11am-12 noon CentralSecond Wednesday of the month 1-2 pm Central

Primary Contact

At the beginning of this registration process, you listed this person as your organization's primary contact for peer review:

Would you like someone different to be the primary contact for SANE Peer Review?

YesNoAs a reminder, the primary contact is responsible for forwarding all links and other communication to team members.

SANE Peer Review Primary Contact

First Name

Last Name

Title

Email Address

Phone number

SANE Peer Review

SANE Peer Review Participants

Please list the names and email addresses of any/all medical providers who will be participating in SANE Peer Review with your site in the coming year.

First Name	Last Name	Email Address

Comments

Forensic Interview Peer Review

Forensic Interview Peer Review Session Selection

Forensic Interview Peer Review will take place on the days/times listed below.

Your site will need to choose one of these times to attend on a consistent basis.

Each site will be required to present at least once during the annual cycle.

If you agree to the conditions above, please indicate a first, second, and third choice for your day/time preference. Every effort will be made to accommodate your first choice selection.

First Choice

Second Choice

Third Choice

Forensic Interview Presentation Slots

Each site is required to present at least once in each annual rotation (January 1, 2024 to December 1, 2024), and we can guarantee up to two presentation slots. If you have multiple interviewers who each need to be peer reviewed, we will make every effort to accommodate additional requested slots, given space availability. How many presentation slots will your site require?

OneTwoOther - Write In

Primary Contact

At the beginning of this registration process, you listed this person as your organization's primary contact for peer review:

Would you like someone different to be the primary contact for Forensic Interview Peer Review?

YesNoAs a reminder, the primary contact is responsible for forwarding all links and other communication to team members.

Forensic Interview Peer Review Primary Contact

First Name

Last Name

Title

Email Address

Phone number

Spanish Speaking Forensic Interview Peer Review

Spanish Speaking Forensic Interview Peer Review Session Selection

Spanish Speaking Forensic Interview Peer Review will take place on the days/times listed below.

Your site will need to choose one of these times to attend on a consistent basis.

Each site will be required to present at least once during the annual cycle.

If you agree to the conditions above, please indicate your day/time preference. Every effort will be made to accommodate your first choice selection.

Third Wednesday of the month 2:30-4 pm CentralThird Thursday of the month 10-11:30 am Central

Primary Contact

At the beginning of this registration process, you listed this person as your organization's primary contact for peer review:

Would you like someone different to be the primary contact for Spanish Speaking Forensic Interview Peer Review?

YesNoAs a reminder, the primary contact is responsible for forwarding all links and other communication to team members.

Spanish Speaking Forensic Interview Peer Review Primary Contact

First Name

Last Name

Title

Email Address

Phone number

Interviewing Individuals with Disabilities Peer Review

Interviewing Individuals with Disabilities Peer Review Session Selection

Forensic Interview Peer Review: Interviewing Individuals with Disabilities will be held six times in 2024 from 1-2:30 p.m. Central.

January 18, 2024
March 21, 2024
May 16, 2024
July 18, 2024
September 19, 2024
November 21, 2024

There will be presenting sites with backup sites assigned for this call.

Would you like to sign up for Forensic Interview Peer Review: Interviewing Individuals with Disabilities?

YesNo

Primary Contact

At the beginning of this registration process, you listed this person as your organization's primary contact for peer review:

Would you like someone different to be the primary contact for Interviewing Individuals with Disabilities Peer Review?

YesNoAs a reminder, the primary contact is responsible for forwarding all links and other communication to team members.

Interviewing Individuals with Disabilities Peer Review Primary Contact

First Name

Last Name

Title

Email Address

Phone number

Payment

If you have any questions about the application, please contact Maggie Larson, Peer Review Program Coordinator, at maggie.larson@childrensmn.org or 612-730-2299.

Thank you for registering for 2024 Peer Review. The final step to complete your registration is to submit payment.

Credit cards are our standard and preferred method of payment. Credit card payments are processed through PayPal. If you do not already have a PayPal account, you will need to establish a (free) username and password in order to process your credit card payment.

If necessary, we can also accept payment by check. Also, for sites who have pre-arranged an alternative payment option (such as a chapter sponsorship), please mark the Check option.

Please indicate which form of payment you will use.

Credit CardCheck

If you have any questions about payment, please contact Kia Kehrer, Program Coordinator, at kia.kehrer@childrensmn.org or 651-895-7115.

Check payment instructions

When paying by check, please follow the instructions below.

Make check out to: Children's Healthcare

Input in memo line: STPL/140101/91038. If your organization name is different than the account name on the check, please add your organization name in the memo line as well.
Send checks to:

Midwest Regional Children’s Advocacy Center

Attn: Children’s Minnesota Midwest Children’s Resource Center

347 N Smith Ave Ste 70-401

St. Paul, MN 55102

A copy of the invoice and our W9 can be found at bit.ly/3CNg8eF.

By clicking Submit, you are completing this portion of the registration and agree to submit your payment by check before participating in the 2024 program.

By clicking Submit, you are completing this portion of the registration. If you need to review any portions of your application, you may navigate to other pages by clicking the Previous Page button before submitting.