Please complete the following information for your facility.

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* 1. Please select your facility from the dropdown list below; facility name and CMS Certification Number (CCN) have been included.

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* 2. Total In Center HD Patient Census

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* 3. Has the project lead for this QIA changed since last submission?

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* 4. Name of person completing this form:

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* 5. Phone Number:
e.g. 123-456-7890

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* 6. E-mail Address:

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 50% of survey complete.

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