Susquehanna Valley Rural Health Partnership

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First Name
Last Name
Mailing Address
City
State
Zip
Telephone
E-Mail Address

Date Need By
Institution		Bucktail Medical Center Jersey Shore Hospital Muncy Valley Hospital
Your Status		Physician Nurse Other
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Deliver Results Via E-Mail Mail/Courier FAX (If not more than pages.)

Purpose of the Search (Check all that apply):

Clinical Question (Patient Care)*   Staff Presentation/Education   Patient/Family Education
Administrative/Management Decision-Making   Plan New Service Facility, etc.
Personal Use      Other

Search Limits (Check all that apply): Years to search   to

Human Only    Age    Sex

Amount of information needed

Adverse Effects/Complications   Diagnosis/Diagnostic Use   Drug Therapy
Epidemology   Etiology   Nursing Care   Organization/Administration
Prognosis   Radiotherapy   Surgery   Therapy/Therapeutic Use

Other Search Limits

State your question/topic in detail; include areas of emphasis and specify points to exclude.
Define terms that have special meaning or may be ambiguous.
Spell out abbreviations/acronyms; e.g., AMI (Acquired Monosaccharide Intolerance).
Suggest synonyms. State the "title" of the article that would best answer your question.

*If possible, use this grid to state patient care questions:

Patient or Problem e.g., In patients with melanoma	Intervention do Oral Contraceptives	Comparison Intervention (vs. No Oral Contraceptives)	Outcome adversely affect prognosis?