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).

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 U.S. 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:

yRynp2FrKWgjdnYWxiWvKwVsvDMyIqxrLoFIJAB9a7nmhcq6M3QsFN8H274coxTwMaADGKqj6bYwWf5gdQRkXwFL7mGCZJhgsSrdfIEWiaMYv8IYzRvxZ5a

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:

* must provide value

Other Facility Name:

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

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?

* must provide value

Yes

reset

Street

* must provide value

City

* must provide value

State

* must provide value

Zipcode

* must provide value

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

Note: This should be the person who would be contacted with critical information after normal business hours

Name of After Hours Contact Person
What department do they work in?
Phone Number
Email address

Director of Nursing Name
Director of Nursing Phone Number
Director of Nursing Email
Director of Nursing 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

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