Please complete the following dialysis facility information.
(One Survey Per Facility CCN)

Overview:
 
Inclusion Criteria: Dialysis facilities that have the lowest vaccination rates in prevalent patients

Project Goals: Obtain hepatitis B (HBV) and pneumococcal (PPV) vaccination rates of  > 60% to graduate out of the multi-year project.

2017 Activities:
1. Provide the name, phone number and email address of the project lead, backup project lead and any other supporting contacts.  Due by: January 23rd, 2017.  
2. Attend kickoff webinar to be held on January 31, 2017 from 9:00 AM-10:00 AM.  During this webinar, the requirements of the entire project will be reviewed.

Instructions:
Please complete all fields in this form, missing fields will result in a rejected form.
Page 1:  Please assign Project Lead and Backup Project Lead. These will be the main contacts for the vaccination project. 
Page 2:  Other Facility Contacts: Please complete this information as it is applicable.  If the person in a listed job title is the same as the project lead or back up project lead, enter "same as project lead" or "same as back up project" lead in the name, phone number and email address field. 
If you facility does not have a person in the job title listed, enter N/A in the name, phone number and email address field. 

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* 1. Please select your facility from the dropdown list below (CMS Certification Number (CCN) and Facility name listed)

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* 2. Project Lead Name: 

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* 3. Project Lead Role:

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* 4. Project Lead Phone Number:
e.g. 123-456-7890

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* 5. Project Lead E-mail Address:

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* 6. Back-up Project Lead:

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* 7. Back-up Project Lead Role:

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* 8. Back-up Project Lead Phone Number:
e.g. 123-456-7890

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* 9. Back-up Project Lead E-mail Address:

 
 50% of survey complete.

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