HAI Advisory Panel Application

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* 1. Required Obligation:

By checking this box, I agree to serve a minimum of 2 years on the HAI Advisory Panel and make myself available for an annual in-person meeting and/or phone/web meetings.

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* 2. Contact Information:

Name

Facility

Title

Credentials

Mailing Address

Telephone Number

Email Address

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* 3. What is your current employment setting?

Ambulatory Surgical Facility

Birthing Center

Children's Hospital

Psychiatric Hospital

Rehab Hospital

Rural Hospital

Non-Rural Hospital

County Nursing Home

For-Profit Nursing Home

Not-for-Profit Nursing Home

Other (please describe)

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* 4. What is your area of specialty?

Infectious Disease

Infection Prevention

Epidemiology

Surgery

Obstetrics/Gynecology

Dentistry

Pharmacy

Nursing

Podiatry

Pediatrics

Geriatrics

Behavioral Health

Facilities Management

Other (please describe)

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* 5. Why are you interested in being a member of the Patient Safety Authority's HAI Advisory Panel?

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* 6. Please attach your CV before submitting this application.

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