Personal Information *Last Name:___________________ *First Name: ____________________ Middle Name:_____________________ *Email address: ______________________________________________
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Facility Identifier *Please select a facility identifier:
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□ CMS Certification Number (CCN) □ AHA ID □ VA Station Code □ CDC Registration ID □ None
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*Selected identifier ID: __________________
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Facility Administrator Role As the NHSN facility administrator, will you have an active role in the collection, entry, and/or analysis of data in NHSN, or provide guidance on the use of protocols for the component(s) in which you are enrolling? _____ Yes _____ No
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