Green Guide for Health Care- Operations Pilot- EXPRESSION OF INTEREST
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Thank you for your recent inquiry re: participation in the 2010 Operations Pilot Program. Please complete this form for review by the Green Guide Operations Pilot team. Thank you.
1
. PRIMARY CONTACT - Please provide your information
PRIMARY CONTACT - Please provide your information
Prefix (Mr./Ms/Dr. etc.)
Name (First Last)
Title/Credential (incl. LEED-AP)
Company
Address1 (Number, Street)
Address2 (City, State, Postal Code)
Country
Telephone/ Fax
E-mail
2
. ALTERNATE CONTACT: Please provide, if applicable
ALTERNATE CONTACT: Please provide, if applicable
3
. Your occupation/ role
Your occupation/ role
Hospital owner/ operator/ administrator
Clinical staff (physician, nurse, etc.)
Non-clinical hospital staff
Health agency/ quasi-governmental agency
Non-profit/Non-governmental organization
Architect/ Engineer
Consultant
Vendor
Other (please specify)
4
. HOSPITAL PILOT INFORMATION - Facility designation (check all that apply)
HOSPITAL PILOT INFORMATION - Facility designation (check all that apply)
Acute care
Children's acute care
Ambulatory care
Rehabilitation care
Long-term care/ Assisted living
Outpatient clinic
Other (please specify)
5
. HOSPITAL PILOT FACILITY - Name, size,location, etc.
HOSPITAL PILOT FACILITY - Name, size,location, etc.
Name of healthcare facility
Address1 (Number, Street)
Address2 (City, State, Postal Code)
Country
Number of beds
Square footage (approx)
Type: Public, Private-for-profit, Private-non-profit, etc.
6
. OPTIONAL: Facility description, example(s) of green operations
OPTIONAL: Facility description, example(s) of green operations
7
. Which area(s) of Green Guide v2.2 are a priority for your pilot project? Check all that apply.
Which area(s) of Green Guide v2.2 are a priority for your pilot project? Check all that apply.
Integrated Operations
Sustainable Sites Management
Transportation Operations
Facilities Management
Chemical Management
Waste Management
Environmental Services
Food Service
Environmentally Preferable Purchasing
Innovation in Operation
8
. Why do you believe your hospital project should be selected as a Pilot?
Why do you believe your hospital project should be selected as a Pilot?
9
. Are you a Practice Greenhealth member?
Are you a Practice Greenhealth member?
Yes
No
Comment
10
. Do you have any additional comments? We welcome your input. ON BEHALF OF THE GREEN GUIDE LEADERSHIP, THANK YOU FOR YOUR EXPRESSION OF INTEREST TO PARTICIPATE IN THE GREEN GUIDE OPERATIONS PILOT FOR 2010!
Do you have any additional comments? We welcome your input. ON BEHALF OF THE GREEN GUIDE LEADERSHIP, THANK YOU FOR YOUR EXPRESSION OF INTEREST TO PARTICIPATE IN THE GREEN GUIDE OPERATIONS PILOT FOR 2010!
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