For your convenience, you may complete this form online by providing information below. Just be aware that this approach requires you to complete the document in one sitting because input is not retained. Alternately, you may click here to download a copy of this form to submit by e-mail or fax
• Re: Hospital Reps - You must have at least 1 designated representative for contact purposes. You may also have up to 2 back up reps (2° and 3°) if desired. For each Rep, please provide their title or position and a preferred telephone number followed by a fax number (e.g., Tel: 124/013-4576, Fax: 124/013-4575)
• Re: Primary Rep - The first name entered into the form will be considered the primary representative for your facility and as such, the first point of contact for questions related to your hospital’s services, sample policies/forms and survey experience. We recommend you consider your Survey Coordinator or PI Director for this role. Again, be sure to provide title or position, phone and fax numbers.
• RE: CEO- As a matter of courtesy, the CEO should always be identified and a separate field is provided for this. However, as a practical matter, the CEO may want to delegate the role of Primary Rep (see above). The CEO e-mail address/telephone will not be displayed and is for our administrative purposes only.
• RE: CFO- CFO informtion is primarily for billing purposes and/or financial questions that might arise. The CFO e-mail address/telephone will not be displayed and is for our administrative purposes only.
•Re: Hospital Name (AAAA) - Provide your hospital’s official name and in parenthesis indicate an abbreviated version using no more than 5 capital letters. For example, Eastern Louisiana Mental Health System (ELMHS)
•Re: # Beds - Complete these boxes only if you have a dedicated program for the population indicated. Note: Adult is only for civil (vs forensic) adults. Do not count adults twice if you list them under a specialty program (e.g., forensic or geriatic).
•Re: Dates - Survey - Please indicate the inclusive dates of the last full or regular survey (e.g., 7/2- 7/6/07)
•Re: Special Programs/Projects- Describe any special initiatives, collaborations, research projects, pilots, etc. (E.g., Joint Commission Core Measures Pilot, NTAC Seclusion Reduction Initiative, Smoke-Free Campus)
