EIP HFA Form (added August 2022)
Att_C1_EIP HFA_Aug22.docx
Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals
EIP HFA Form (added August 2022)
OMB: 0920-0852
Form
Approved OMB
No. 0920-0852 Exp.
Date 03/31/2025
Form
Approved OMB
No. 0920-XXXX
Exp.
Date xx/xx/20xx
Form
Approved OMB
No. 0920-XXXX
Exp.
Date xx/xx/20xx
EIP HEALTHCARE FACILITY ASSESSMENT—FOR EIPT USE ONLY
Hospital ID: ________________________ Survey date: //
Enter the date on which you are completing this form: //
Enter your initials: _________
Is the hospital located in an urban or rural area?
☐Rural
☐Urban
☐Unknown
Does the hospital have an American Medical Association (AMA)-approved residency program?
☐Yes
☐No
☐Unknown
Is the hospital a member of the Council of Teaching Hospitals (COTH)?
☐Yes
☐No
☐Unknown
Phase 5 Prevalence Survey EIP HFA_20220516
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Shelley Magill |
| File Modified | 0000-00-00 |
| File Created | 2022-08-04 |
© 2024 OMB.report | Privacy Policy