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

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

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

The value you provided is outside the suggested range

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).

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.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

7qXNJbLtIMPJfDGjXwJrQ3MoGV2FTVYe5p2sBESBKHNdqcSUJezwVEpbMYn6JnebaU8KxkPJYebEgXzVjgPyzmwU4Xg6Ep5AcxJzmPjjgiAsaEGtyJQYgk6rLP

Facility Contact Inventory

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:

Other Facility Name:

Facility Name:

* must provide value

Other (Facility Name not listed):

* must provide value

Facility Type (Check all that apply)

Note: If you have different staff that work in the different facility types, we ask that you please fill out a separate survey for each 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 (Ambulatory Surgical Center)

Other

Rural Health Center (RHC)

Outpatient Clinic

Dental Office

If Other, please specify

* must provide value

Street

* must provide value

City

* must provide value

State

* must provide value

Zipcode

* must provide value

County

* must provide value

County Other:

* must provide value

Phone Number

* must provide value

Fax

Please specify your website address if you have one.

Is your mailing address the same as the facility address?

Yes

reset

Street

City

State

Zipcode

Infection Preventionist Name*
Infection Preventionist Phone Number*
Infection Preventionist Email*
Infection Preventionist Fax*

Alternate Staff Member Name*
What is the Staff Member's title/ role?*
Alternate Staff Member Phone Number*
Alternate Staff Member Email*

Staff Fax

Note: This would be a direct person who would be contacted with critical information after Normal Business Hours during Weekdays AND over the Weekend.

Name of After Hours Contact Person*
What is the Contact's title/ role?*
Phone Number*
Email address

Director of Nursing or Administrator Name*
Director of Nursing or Administrator Phone Number*
Director of Nursing or Administrator Email*
Director of Nursing or Administrator Fax*

Administrator/Executive Director Name
Administrator/Executive Director Number
Administrator/Executive Director Email
Administrator/Executive Director Fax

Medical Director Name
Medical Director Phone Number
Medical Director Email
Medical Director Fax

Medical Director Name
Medical Director Phone Number
Medical Director Email
Medical Director Fax

Micro Lab Contact Name
Micro Lab Contact Phone Number
Micro Lab Contact Email
Micro Lab Contact Fax

Antibiotic Stewardship Contact Name
Antibiotic Stewardship Contact Phone Number
Antibiotic Stewardship Contact Email
Antibiotic Stewardship Contact Fax

Quality Director Name
Quality Director Phone Number
Quality Director Email
Quality Director Fax

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.