Step One: CONTACT & FACILITY INFORMATION

Your Name:      Title:      Hospital/Facility:  
    
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

Total Beds:     Last Joint Commission Survey:  

Step Two: POSITION SPECIFICATIONS

Position Title:     Title of the individual position reports to:  

Role: Select One Sole Practitioner Team Member Manager Director   How long vacant: How many ICPs currently in department:  

RN Required (Registered Nurse)  MT(ASCP) and MPH candidates will also be considered

CIC (Certified Infection Control): Select One CIC Required CIC Preferred Within 2 Years   Degree: Select One Degree Not Required Associates Preferred Associates Required Bachelors Preferred Bachelors Required Masters Preferred Masters Required   IC experience: Select One 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years +

Does IC Dept. have secretarial or data-entry support: Select One Designated Shared None   Also handles Employee Health: Select One Yes No  

Salary: Select One Paid Hourly Base Salary   Status: Select One Exempt Non-Exempt   Pay Range: (Low):   (Medium):   (High):

Annual Bonus: Select One Yes No   If Yes, Annual Bonus Info/Percentage:

Relocation assistance provided: Select One Yes No If yes, how determined: Select One Flate Rate Case By Case   Sign-on Bonus Select One Yes No Amount:

How is your surveillance data collected/managed: Select One Manually Access, Excel, Etc. Aice Epi Systems MedMined TheraDoc SafetySurveillor Other Vendor
              
Add general comments / special instructions / additional information here


Paste internal job description here (optional)


Your request will be handled promptly and confidentially.  A confirmation email will be sent by an Account Manager
along with your quote.

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