The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

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Required format:

TWnbwe99j8TUCVSArBGv8T4TLBL2mQHa929u8kkL5fvAgbMpTAUN4LBsAkFBQshVe7DsLkMLKafQbwIj2SRkFJQhnIs5QcNVKuYYVd3HcoGuV6y

Facility Contact Inventory

Hello,

We are updating our contact lists of all the infection preventionists and/or facility points of contact. Please complete the survey below so we have the most updated information.

Thank you!

Facility Name

* must provide value

Facility Type

* must provide value

Acute care hospital

Long-term acute care hospital

Critical access hospital

Inpatient rehabilitation facility

Nursing home/skilled nursing facility

Intermediate care facility*

Assisted Living/residential care home

Dialysis facility

CMS-certified ASC

Other

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If Other, please specify

* must provide value

Total Licensed Beds

* must provide value

NHSN # (if applicable)

CLIA # (if applicable)

Medicare/Medicaid Number (if applicable)

Medical Director Name

Medical Director Phone

Medical Director Fax

Medical Director Email

Name

* must provide value

Phone

* must provide value

Fax

* must provide value

IP Name

* must provide value

IP Phone

* must provide value

IP Fax

* must provide value

IP Email

* must provide value

Number of Full Time IP

* must provide value

No IP Present

1 FTE

More than 1 FTE

Less than 1 FTE

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If more than 1 FTE, specify how many?

* must provide value

If Less Than one, % of time the IP is devoted to the Infection Prevention?

* must provide value

Trained in Infection Prevention and Control

* must provide value

Yes

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Certified in Infection Control

* must provide value

Yes

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Health System Affiliation (if applicable)

Accreditation

Street

* must provide value

City

* must provide value

County

* must provide value

Local Health Department

* must provide value

If not listed, please specify

* must provide value

State

* must provide value

Zipcode

* must provide value

Phone

* must provide value

Fax

* must provide value

Please specify your website address if you have one.

Is mailing address same as above?

* must provide value

Yes

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If different, please enter details below.

Street

* must provide value

City

* must provide value

State

* must provide value

Zipcode

* must provide value

Phone

* must provide value

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