Green Guide for Health Care- Operations Pilot- EXPRESSION OF INTEREST

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.

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* 1. 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

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* 2. ALTERNATE CONTACT: Please provide, if applicable

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* 3. 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)

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* 4. 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)

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* 5. 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.

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* 6. OPTIONAL: Facility description, example(s) of green operations

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* 7. 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

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* 8. Why do you believe your hospital project should be selected as a Pilot?

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* 9. Are you a Practice Greenhealth member?

Yes

Comment

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* 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!