HOSPITAL ACCREDITATION SURVEY APPLICATION

PART 1
Please provide the date that your organization began providing clinical
services.
//
dd / mm / yyyy

I. ORGANIZATION INFORMATION
1. Organization Name: (The entry text below, as entered, will be used
for your certificates. Only a maximum length of 80-characters is
allowed.)
______________________________________________________________

II. INPATIENT SERVICES

A. Volume
2. Total number of inpatient beds:

3. The average number of inpatient beds that are occupied daily:

4. Total emergency department visits per year:

5. Check all applicable Clinical Medical Services or Units currently

provided by the Organization: (Please add at the bottom under
Other, any services provided that do not appear on this list)

Check all that apply

Ambulatory ICU Medical Otolaryngology
Anesthesiology ICU Neonatal Pediatrics
Blood bank ICU Neurosurgical Pharmacy-Outpatient
Cardiac catheterization ICU Pediatric Pharmacy-Inpatient
Physical
Cardiac Surgery ICU Surgical Therapy/Physiology
Cardiology Infectious Diseases Plastic Surgery
Interventional
Day hospital Radiology Podiatry
In vitro Fertilization
Day surgery (IVF) Pulmonary Medicine
Dental Surgery Immunology Psychiatry
Dentistry Labor and Delivery Psychology
Dermatology Laboratory Radiology
Dialysis Inpatient Maxillofacial surgery Radiation Therapy
Rehabilitation
Dialysis - Outpatient Medical - General Medicine
Emergency Medicine Nephrology Renal medicine
Endocrinology Neurology Renal surgery
Endoscopy Neurosurgery Research

Hospital Survey Application Page 1 of 5

 Family & Community
Medicine Nuclear Medicine Respiratory Medicine
Gastroenterology Nursery Respiratory Therapy
Geriatric Medicine Obstetrical Rheumatology
Gynecology Occupational Therapy Surgical General
Hematology Oncology Thoracic surgery
Histopathology Ophthalmology Urology
ICU Burn Unit Organ Transplant Vascular surgery
ICU Cardiology Orthopedics

6. In-Patient Care Units/Wards: Using the table below please list each
Inpatient Care Unit/Ward including the additional information requested.
See the example in the first two lines.
Please check the last column only if Anesthesia/Sedation1.is
administered in the location listed.

Name of Avera Type of Floor Building Check here

Unit/Ward ge Care Given Name if
Daily Anesthesia
Censu /
s2 Sedation
Administer
ed
Example: Ward A 32 Surgical Intensive 3 Main site
Care
Example: Ward B7 10 Mental Health 2 Building C

1
The administration to an individual, in any setting, for any purpose, by any route, medication to induce a partial or total loss of sensation for
the purpose of conducting an operative or other procedure.
2
The average number of inpatient beds on each unit/ward occupied daily.

Hospital Survey Application Page 2 of 5

 Name of Avera Type of Floor Building Check here
Unit/Ward ge Care Given Name if
Daily Anesthesia
Censu /
s Sedation
Administer
ed

Hospital Survey Application Page 3 of 5

 7. List the type of surgical/operating room theaters, the number you
have, and the building in which they are located.
(Include all buildings or sites whose surgery is provided and each
location within every building,, such as obstetrics operating theater,
general operating theater, cardiac operating theater, pediatric operating
theater, outpatient operating theater, and so on.)
Operating Theater Number Building Name

II. OUTPATIENT SERVICES

A. Volume
8. Total number of outpatient visits for the last full year:

9. Total number of holding3 or observation4 beds:

10. Total number of surgical procedures for the

last full year:

11. List Outpatient Units, the number of annual

visits, and the type of service provided.
(Example: Surgical clinic, 150 visits per month, pre and post operative
procedure evaluation and treatment).
NOTE: If you require additional form(s) please click on this link (Ctrl +
Click), which will take you to #41a/page 26 or scroll down to page 26.
Complete as many forms as necessary and submit all completed forms
with your survey application.
Name of Numbe Type of Floor Building Anesthesi
Outpatient Unit or r of Care Given Name a/
Clinic Annual Sedation
Visits Administe
red
Sample: Surgery 5 Pre and post operative 1 Building G
Clinic procedure evaluation and
treatment
Sample: Behavioral 10 Mental Health 1 Main Site
Health Outpatient
Clinic

3
A bed occupied by a person for short term observations
4
The beds assigned to non-emergency patients who reside less than 24 hours observation of a medical condition.

Hospital Survey Application Page 4 of 5

 Name of Numbe Type of Floor Building Anesthesi
Outpatient Unit or r of Care Given Name a/
Clinic Annual Sedation
Visits Administe
red















Total Number of 0
Annual Visits

Hospital Survey Application Page 5 of 5