2018 KISS Attestation Survey

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* 1. Hospital

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* 2. Address

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* 3. City

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* 4. State

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* 5. Zip Code

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* 6. General Phone Number

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* 7. Attestation Date

Date / Time

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* 8. CEO Name

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* 9. CEO Phone

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* 10. CEO Email

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* 11. Stroke Medical Provider Name

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* 12. Provider Phone Number

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* 13. Provider Email

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* 14. Marketing/PR Phone

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* 15. Marketing Contact Name

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* 16. Marketing/PR Email

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* 17. ED Nurse Manager

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* 18. ED Nurse Manager Phone

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* 19. ED Nurse Manager Email

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* 20. EMS Provider

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* 21. EMS Contact Name

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* 22. EMS Phone

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* 23. EMS Email

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* 24. EMS 2 Provider

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* 25. EMS 2 Contact Name

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* 26. EMS 2 Phone

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* 27. EMS 2 Email

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* 28. Alteplase Available for Stroke

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* 29. 24/7 CT

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* 30. CT Scanner Slice #

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* 31. 24/7 Blood Coag.

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* 32. Plan to Transfer to Appropriate Neurosurgical/Neuro-Interventional/Stroke Expertise:

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* 33. Where will these patients be transferred to, if needed?

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* 34. Implemented Emergent Stroke Care Protocol

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* 35. Hospital will submit HIPAA compliant data monthly on stroke patients

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* 36. Data Abstractor Name

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* 37. Data Abstractor Phone

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* 38. Data Abstractor Email

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* 39. Are you a part of the Heart and Stroke Collaborative?

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* 40. Willing to be listed on a statewide capability map

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* 41. Hospital will provide community stroke education

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* 42. Community Education Date

Date / Time

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* 43. What Community Education Program

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* 44. 2018 # of Acute Ischemic Strokes

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* 45. 2018 # of Hemorrhagic Strokes

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* 46. 2018 # of Alteplase Treatments for Stroke

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* 47. 2018 # of transfers for intervention/care

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