AMS Survey Questions

Question Title

* 1. What is your name and what facility are you reporting for?

Question Title

* 2. Does your hospital have (a) long term care facility or facilities under your hospital's corporate or not for profit administrative umbrella?

Yes

No

If yes, please name the facility or facilities.

Question Title

* 3. Does your hospital have (an) outpatient facility/facilities under your hospital's corporate or not for profit administrative umbrella?

Yes

No

If yes, please name the facility or facilities.

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* 4. Does your hospital have (a) dialysis facility or facilities under your hospital's corporate or not for profit administrative umbrella?

Yes

No

If yes, please name the facility or facilities.

Question Title

* 5. If you have facilities that fall under your administrative umbrella, are they integrated into your Antimicrobial Stewardship program? Please select all that apply.

Outpatient

Long Term Care

Dialysis

Not Applicable

Please include any comments that you have.