This self-assessment is intended to help your organization evaluate your current practices for preventing Clostridium difficile infection (CDI) and identify the process improvements implemented while participating in the CDI collaborative. This tool is based on the Centers for Disease Control and Prevention CDI pre-assessment and Society for Healthcare Epidemiology of America 2010 guidelines.

Please complete the following background questions regarding your facility’s current status.

* 1. Facility Name:

* 2. City/County:

* 3. Date:

* 4. Name and Title of Person Completing this Survey:

* 5. Email address:

* 6. What is the total number of staff currently working in your infection prevention & control department? (Please describe using full-time equivalents of people working directly in infection prevention and control. For example, if a facility had one full-time and one half-time infection control person, this would equal 1.5 staff members. Do not include support staff.)

* 7. How many employees are currently dedicated to your facility’s infection control program?

* 8. How many staff working in infection control are certified in infection control?

* 9. Currently, how many beds does your facility have?

Please provide the following background information regarding your facility’s current practices for preventing and controlling the spread of CDI.

* 10. How great a priority is prevention and control of Clostridium difficile Infection (CDI) at your facility?

* 11. Does your facility have a committee that reviews infection control-related activities (such as reports, policies and procedures, etc.)?