HANYS Antibiotic Stewardship Collaborative

Organization Authorization

HANYS Antibiotic Stewardship Collaborative provides healthcare organizations across the continuum of care with the opportunity to join together and learn from each other as they accelerate their antibiotic stewardship efforts, with the goal of combating the growing threat of drug-resistance.

My organization agrees to start or continue our antibiotic stewardship journey, by participating in the HANYS Antibiotic Stewardship Collaborative in a manner that best fits the needs of our organization in our mission to improve healthcare quality, outcomes, and efficiency.

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* 1. Please select your facility

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* 2. Authorized Representative

Name

Title

Department

Phone

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* 3. I agree to have my organization's name published on the HANYS website to demonstrate my organization’s commitment to this statewide effort.

Yes

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* 4. Primary Contact

First Name

Last Name

Title

Telephone

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* 5. Pharmacist Champion

First Name

Last Name

Title

Telephone

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* 6. Laboratory Champion

First Name

Last Name

Title

Telephone

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* 7. Physician Champion

First Name

Last Name

Title

Telephone

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* 8. Nurse Champion

First Name

Last Name

Title

Telephone

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* 9. Data Analytics Champion

First Name

Last Name

Title

Telephone

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* 10. Antibiotic Stewardship Team Member

First Name

Last Name

Title

Telephone

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* 11. Antibiotic Stewardship Team Member

First Name

Last Name

Title

Telephone

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* 12. Antibiotic Stewardship Team Member

First Name

Last Name

Title

Telephone