Your First Name:    Last Name:         

Title:   

Hospital/facility name:  
    
Address:  

City:     State:   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code:             

Phone #:     Ext: 

 e-Mail:  

How do you prefer to be contacted: Email  Phone  Either

Facility Type: Acute Care Hospital  Critical Access Hospital

Long-term Acute Care  Long-term Care  Skilled Nursing

Other facility type 

Please list facilities outside the main hospital (sister hospitals, skilled nursing facility, LTC facility, clinics, etc.) that the Infection Preventionist will also responsible for:


Total beds main facility:    Licensed beds:   Daily census:   

Date of last Joint Commission Survey (if applicable):

If not The Joint Commission how accredited:

Step Two: POSITION SPECIFICATIONS

Preferred Interim assignment start date:   

Projected length of assignment:   

Reason for assignment:   Select One JCAHO Survey Due CMS Data Surveillance Data No ICP Maternity Leave Medical Leave Back-Up Team Support IC Program Assessment IC Program Improvement Education/Training Other

Type of role: Select One Sole Practitioner Team Member Manager Director

Title of individual Interim will report to:  

How many Infection Preventionists in dept. excluding the Interim: 

How is your surveillance data collected/managed:  Select One Manually Access, Excel, Etc. Aice Epi Systems MedMined TheraDoc SafetySurveillor Other Vendor

Surveillance data collected/managed (other than above):


Does IC Department have secretarial or data-entry support:   Select One Designated Shared None

Will the Interim also handle Employee Health:   Select One Yes No
    
Please check all that are appropriate below:

RN Required (Registered Nurse)

All qualified RN, MT(ASCP) and MPH candidates will be considered

CIC (Certification in Infection Control):  Select One CIC Required CIC Preferred

Degree:  Select One Degree Not Required Associates Preferred Associates Required Bachelors Preferred Bachelors Required Masters Preferred Masters Required

Add general comments / special instructions / additional information here

Your request will be handled promptly.  A confirmation email will be sent shortly and one of our Account Managers will contact you directly.

Thank you for your valuable time and we look forward to earning your business.
 
Step Three:   Send request to Galileo Search     Start over

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