IDSA Antimicrobial Stewardship Centers of Excellence Program

Application for CoE Designation

The IDSA Antimicrobial Stewardship Centers of Excellence program is intended to recognize health care facilities that implement and maintain highly effective ASPs. IDSA acknowledges that many institutions are part of health systems; however, the CoE Core Criteria was developed to assess the resources and capabilities of a single institution. The CoE designation will not apply to an entity that provides services that support, in whole or in part, the AS program of an institution; therefore, each facility is required to apply on an individual facility basis. If you are applying as a healthcare system/network, please contact CoE staff at ascoe@idscoiety.org before applying. Please be prepared to provide evidence of stewardship activity and practices across each of the facilities seeking designation.

If your institution meets the criteria for the Centers of Excellence program, there will be a $5,000 license fee for the 2-year designation.

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* 1. Legal Name of Hospital or Long-Term Care Facility:

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* 2. Address

Street Address Line 1:

Street Address Line 2:

City:

State:

Zip:

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* 3. Facility website URL:

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* 4. Primary Facility Contact Information:

Name:

Title:

Phone Number:

Email:

Is primary contact an IDSA member?

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* 5. Secondary Facility Contact Information:

Name:

Title:

Phone Number:

Email:

Is secondary contact an IDSA member?

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* 6. Is your facility part of a — (select all that apply):

Hospital Network

Health System

Free-standing

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* 7. Number of FTEs dedicated to antimicrobial stewardship:

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* 8. Ownership:

For-Profit/Private

Not for Profit

Government

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* 9. Average Number of Beds:

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* 10. Facility type:

Academic

Community

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* 11. EHR/EMR Reporting System:

Epic

Cerner

Allscripts

NextGen

Other

IDSA Antimicrobial Stewardship Centers of Excellence Program

Application for CoE Designation

Question Title

* 1. Legal Name of Hospital or Long-Term Care Facility:

Question Title

* 2. Address

Question Title

* 3. Facility website URL:

Question Title

* 4. Primary Facility Contact Information:

Question Title

* 5. Secondary Facility Contact Information:

Question Title

* 6. Is your facility part of a — (select all that apply):

Question Title

* 7. Number of FTEs dedicated to antimicrobial stewardship:

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* 8. Ownership:

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* 9. Average Number of Beds:

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* 10. Facility type:

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* 11. EHR/EMR Reporting System:

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* 12. If you answered other, please specify: