Facility Contact Inventory Form

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This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

Timely communication is vital to improving healthcare outcomes. Please complete this contact list to ensure your facility can receive critical public health updates from the Nebraska DHHS HAI/AR program, including admission alerts for patients colonized with extensively drug-resistant organisms (XDRO).

Please note that sections marked with (*) are required.

Last update date

View equation

ICAP ID

Facility Name

* must provide value

Facility Name (Note. Please choose your facility from the dropdown, select other if not found)
Facility Type (Note. Please use the licensure roster (https://dhhs.ne.gov/licensure/Pages/Rosters-of-Facilities-and-Services.aspx) to be as accurate as possible when choosing facility type(s). If there are different point of contact for different facility type, then please fill out a separate survey for those facility types)
Street Address (e.g., 123 Main St)
City
State
ZIP
County if in Nebraska
Facility Phone (e.g., (123) 444-5443)

Infection Preventionist First Name
Infection Preventionist Last Name
Infection Preventionist Job Title
Infection Preventionist Email
Infection Preventionist Phone	Phone Extension (if any)
Infection Preventionist Secure Fax (Please enter NA if no fax)

Alternate Staff First Name
Alternate Staff Last Name
Alternate Staff Job Title
Alternate Staff Email
Alternate Staff Phone	Phone Extension (if any)

After Hours Contact First Name
After Hours Contact Last Name
After Hours Contact Job Title
After Hours Contact Phone	Phone Extension (if any)
After Hours Contact Email (Please enter NA if no email)

Contact First Name
Contact Last Name
Contact Job Title
Contact Email

All information above is correct as of the date:

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