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* 1. Facility Name

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* 2. Type of Facility (Skilled Nursing Facilities: we will utilize your National Healthcare Safety Network [NHSN] data for inclusion and award eligibility. Please continue to report in NHSN.)

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* 3. Facility License Number:

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* 4. Point of contact/Submitter name:

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* 5. Contact phone number with area code:

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* 6. Contact email:

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