Please complete the following information and checkboxes indicating which activity was selected.
 
WARNING:
DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SS # IN THIS SURVEY.
SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

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* 1. Facility Name:

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* 2. Six-digit CMS Certification number (begins with a 45 or 67):

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* 3. First and Last name of the person completing this survey:

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* 4. Title of the person completing this survey:

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* 5. Phone Number

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* 6. UPI number of patient(s) that assisted with the selection of this activity: (Do NOT list patient names)

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* 7. Grievance Quality Improvement Activity Options
Select THREE activities (one preselected):

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* 8. Grievance Quality Improvement Activity Options
Mental Health Education: MANDATORY - Choose one

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