Att J_EIP Healthcare Facility Assessment

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
EIP HEALTHCARE FACILITY ASSESSMENT—FOR EIPT USE ONLY

Hospital ID: ________________________

/

Survey date:

1) Enter the date on which you are completing this form:

/

/

/

2) Enter your initials: _________
3) Is the hospital located in an urban or rural area?
☐Rural
☐Urban
☐Unknown
4) Does the hospital have an American Medical Association (AMA)-approved residency program?
☐Yes
☐No
☐Unknown
5) Is the hospital a member of the Council of Teaching Hospitals (COTH)?
☐Yes
☐No
☐Unknown

Phase 4 Prevalence Survey EIP HFA_20150227