Attachment B - Survey Screen Shots

Section1_Background_Pleas

Section 1: Background:
Please complete the following background information about your facility.

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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:19:05 AM

Department of
Health
and Human
Services

DateOfSurveyCompletion

Date of survey completion (mm/dd/yyyy):

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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:19:16 AM

Department of
Health
and Human
Services

StateOfFacility

State of facility:
GA

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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:19:36 AM

Department of
Health
and Human
Services

WhichOfTheFollowingEntiti

Which of the following entities are found within your facility (check all that apply)?
✔

Acute (short term) inpatient care facility (for example, acute care hospital)

Long term inpatient care facility (for example, nursing home or rehabilitation
facility)
Ambulatory care facility (for example, urgent care center or doctor’s office)
Other, describe
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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:19:47 AM

Department of
Health
and Human
Services

The

In the past year, what is the total number of staff working in infection control at your
facility? Please describe using full-time equivalents (for example, if a facility had one
full-time person and 1 half-time person, this would equal 1.5 staff members).

Don't know
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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:20:00 AM

Department of
Health
and Human
Services

NumBeds

In 2007, how many active hospital beds does your facility have?

Don't know
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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:20:18 AM

Department of
Health
and Human
Services

NumICUBeds

In 2007, how many active adult Intensive Care Unit beds (ICU) does your facility
have?

Don't know
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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:20:39 AM

Department of
Health
and Human
Services

NumNonICUBEDS

In 2007, how many active non-ICU pediatric beds does your facility have?

Don't know
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Stop
Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:20:52 AM

Department of
Health
and Human
Services

TeachingFac

Is your facility a teaching facility (for this survey that means your facility has
physicians-in-training and/or nurses-in-training providing care to patients)?

Yes
Yo
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Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA
30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

https://www3a.ncid.cdc.gov/mrIWeb/mrIWeb.dll8/2/2007 11:21:05 AM

Department of
Health
and Human
Services