PSC/CSC ADDENDUM TO Combined NIAHO® AND ISO 9001 Application: Individual Hospital With Related Services and/or sitES Applications must be completed electronically (Handwritten applications will not be accepted) Contact Information Hospital Name: City: State: Stroke Coordinator Name: Stroke Coordinator Phone: Email: Additional Stroke Certification Sites ASC MILES PSC SITE NAME ADDRESS CITY, STATE, ZIP TO MAIN or CAMPUS CSC ONLY ACUTE STROKE READY Enter PSC/CSC information on the following page ASR Application Eligibility Verification Requirement Organization Data Procedure Yes No Acute Stroke Ready team available 24/7 Yes No Written protocol for Acute Stroke triage and diagnosis Yes No Written agreement/plan with primary EMS agency Yes No Labs, CT and Imaging available 24/7 Yes No Written emergency stroke treatment protocol Yes No Neurosurgical coverage plan Yes No Transfer agreement and protocol with PSC/CSC facility Yes No Designated medical director Yes No Designated stroke coordinator Yes No Telemedicine agreement/equipment policy and procedure
PSC/CSC ADDENDUM TO Combined NIAHO® AND ISO 9001 Application: Individual Hospital With Related Services and/or sitES Applications must be completed electronically (Handwritten applications will not be accepted) Contact Information Hospital Name: City: State: Stroke Coordinator Name: Stroke Coordinator Phone: Email: Additional Stroke Certification Sites SITE NAME ASC PSC or CSC ADDRESS CITY, STATE, ZIP MILES TO MAIN CAMPUS ACUTE STROKE READY ONLY Enter PSC/CSC information on the following page ASR Application Eligibility Verification Requirement Organization Data Procedure Acute Stroke Ready team available 24/7 Yes No Written protocol for Acute Stroke triage and diagnosis Yes No Written agreement/plan with primary EMS agency Yes No Labs, CT and Imaging available 24/7 Yes No Written emergency stroke treatment protocol Yes No Neurosurgical coverage plan Yes No Transfer agreement and protocol with PSC/CSC facility Yes No Designated medical director Yes No Designated stroke coordinator Yes No Telemedicine agreement/equipment policy and procedure Yes No
ICP-12-4-i1-f2-Application-Stroke-03-11-2015.docx