JHAH CUSP/CLABSI Team Registration Form Name of hospital Johns Hopkins Aramco Healthcare (JHAH) Intensive Care units How many ICU step-down units will be taking the HSOPS survey? Name of each ICU and step-down unit and number of people who spend most of their work time in each ICU unit or step-down unit/work area? (Including nurses, physicians, technicians, support staff, administrators, and others who spend 60% or more of their work time working in this unit/work area) Name of ICU or step-down unit Name of department (Critical Number of people who spend (please specify) Care, etc.) 60% or more of their work time in this unit/work area (this will be the denominator for this unit’s survey response rate) CUSP/CLABSI PROJECT ADMINISTRATION For each ICU or step-down unit identify the following: 1. Nurse Manager Supports CUSP process Assists in scheduling executive walk rounds Manages resources May serve as the Unit Champion (will need Assures survey results are shared with staff 20% dedicated effort) Assigns project leaders to interventions ICU/Step-down Unit Nurse Manager address
JHAH CUSP/CLABSI Team Registration Form Name of hospital Johns Hopkins Aramco Healthcare (JHAH) Intensive Care units How many ICU step-down units will be taking the HSOPS survey? Name of each ICU and step-down unit and number of people who spend most of their work time in each ICU unit or step-down unit/work area? (Including nurses, physicians, technicians, support staff, administrators, and others who spend 60% or more of their work time working in this unit/work area) Name of ICU or step-down unit (please specify) Name of department (Critical Care, etc.) Number of people who spend 60% or more of their work time in this unit/work area (this will be the denominator for this unit’s survey response rate) CUSP/CLABSI PROJECT ADMINISTRATION For each ICU or step-down unit identify the following: 1. Nurse Manager Supports CUSP process Manages resources Assures survey results are shared with staff Assigns project leaders to interventions Assists in scheduling executive walk rounds May serve as the Unit Champion (will need 20% dedicated effort) ICU/Step-down Unit Nurse Manager address
JHAH_HSOPS_Registration_Form_2014.11.03_v1.docx