PCSI 2012 Casemix Winter School 
 “Design and Implementation of Activity Based Funding”
Student Application Form

Once you have completed this application form, please email it to Jeff Hatcher, the 
school director at the following email address: jhatcher@cihi.ca 

First Name:              Surname:              Title: 
Country of Residence:      
Email Address:      
Mailing Address:      
Daytime Telephone Number:       

Present Employment
Company/Organization:       
Position/title:      

Professional Degrees, Diplomas, and Certificates
	Educational Institution	Title of Degree, Diploma, or Certificate	 Year of Completion	
1	     	     	     	
2	     	     	     	
3	     	     	     	

Please rate your level of experience in the following areas: 
Area	Knowledge Rating	
Diagnosis or procedure classification systems (e.g. ICD-9/10)		
Casemix systems (DRG, Nord-DRG, HRG, etc)		
Case weight calculation		
Activity-Based Funding and other hospital payment systems		
Statistical Concepts (probability, expectations, densities, distributions, etc)		
Statistical Inference (confidence intervals, hypothesis tests, p-values, etc)		
Statistical modeling		
Use of R statistical software 		
Use of other statistical software (e.g. SPSS, SAS, STATA)		
Ability to work and study in the English language		

Please describe in 100 words your current and past professional involvement in casemix and hospital payment systems.
     

Please describe in 100 words or less why you want to attend the PCSI Winter School and how it will contribute to your professional development.