A Study to Improve Dementia Care in Nursing Homes
PARTICIPANT RESPONSE FORM
(
*
Denotes a required field. )
FACILITY INFORMATION
*
FACILITY NAME:
*
STREET ADDRESS:
*
CITY:
*
STATE:
--
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
*
ZIP CODE:
(in xxxxx format)
*
COUNTY:
FACILITY ID NUMBER:
What's this?
*
BED SIZE:
*
PROFIT STATUS:
Not-For-Profit
For-Profit
County or Public
State
Federal
Don't Know
LIST ANY SPECIALTY UNITS:
PROJECT CONTACT INFORMATION
*
LAST NAME:
*
FIRST NAME:
*
TITLE:
*
PHONE NUMBER:
(in xxx-xxx-xxxx format)
*
E-MAIL ADDRESS:
*
Confirm E-MAIL ADDRESS:
CURRENT EQUIP USER?:
Yes
No
EQUIP for Quality c/o Linda Spokane
150 State Street Suite 301, Albany, NY 12207
Tel:518-449-2707 ext. 123 -- Fax:518-689-2149
[
close
]