Getting to Zero: Central Line Infections (CLI)
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Your Information
Please enter information about your hospital below
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1
. What is the name of your hospital?
(Note: This survey is designed for a single hospital's answers. If you are a system contact and represent multiple hospitals that you would like to report on, please fill out separate surveys for each such hospital in your system.)
What is the name of your hospital? (Note: This survey is designed for a single hospital's answers. If you are a system contact and represent multiple hospitals that you would like to report on, please fill out separate surveys for each such hospital in your system.)
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2
. In what city and state is your hospital located?
In what city and state is your hospital located?
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3
. Who can we contact at your hospital if we have questions about your CLI work? (Please enter either phone number or email address, or both, in the space provided.)
Who can we contact at your hospital if we have questions about your CLI work? (Please enter either phone number or email address, or both, in the space provided.)
Name
Job Title
Phone and/or Email
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4
. May IHI identify, in public materials, the individual identified above (including his or her contact information) as someone other hospitals, members of the media, and/or the general public may contact with questions about your CLI work?
May IHI identify, in public materials, the individual identified above (including his or her contact information) as someone other hospitals, members of the media, and/or the general public may contact with questions about your CLI work?
Yes
No
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