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 (Approximate Date) :  

Step Two: POSITION SPECIFICATIONS

Title of individual position reports to:   Role: Select One Sole Practitioner Team Member Manager Director   Reason: 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

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

Projected assignment start date:   Projected length of assignment:  

Does IC Department have secretarial or data-entry support: Select One Designated Shared None   Does the ICP also handle Employee Health: Select One Yes No
    
Please check all that are appropriate below

RN Required (Registered Nurse)  Will you also consider an experienced MT(ASCP) or MPH 

CIC Preferred (Certified Infection Control)  CIC Required

General comments / special instructions / additional information
 

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