Applicant Information

Facility Name:

Medicare Provider #:

Facility NPI # :

Name of Project Contact Person (at your facility):

Job Title :

Email:

Phone:

Please indicate below the modules your facility is interested in completing:

Patient Safety Principles * (Mandatory module for all participants)
Decreasing Dialysis Patient & Provider Conflict (DPC)
Emergency Preparedness
Flu Vaccination
Hand Hygiene
Medication Reconciliation
Missed Treatments
Sharps Safety
Slips, Trips, & Falls
Other (please indicate: )

Thank you for your dedication to patient safety issues within the dialysis community.