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

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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

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: //



  1. Enter your initials: _________



  1. Is the hospital located in an urban or rural area?

Rural

Urban

Unknown


  1. Does the hospital have an American Medical Association (AMA)-approved residency program?

Yes

No

Unknown


  1. Is the hospital a member of the Council of Teaching Hospitals (COTH)?

Yes

No

Unknown




Phase 5 Prevalence Survey EIP HFA_20220516


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorShelley Magill
File Modified0000-00-00
File Created2022-08-04

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