STRIVE Cohort 4 Registration Form

Registration

Welcome to STRIVE! To complete this registration form, you will need demographic information about your hospital (i.e. capacity, ownership, admissions, etc.), your hospital's Medicare number and NHSN Org ID, and the names, email addresses, and phone numbers of the employees who plan to be involved in the STRIVE project.

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* 1. Your Name

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* 2. Your Email Address

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* 3. Hospital Type

Long Term Acute Care Hospital (LTACH)

Acute Care Hospital (ACH)

Critical Access Hospital (CAH)

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* 4. Hospital Name

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* 5. Medicare Number (if applicable)

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* 6. Address

Street

City

State (abbreviation only)

ZIP