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2. Facility & Contact Information
4. Facility Name*
6. Facility Type
   -- Select One --Skilled Nursing FacilityAssisted Living FacilityAdult Family HomeDental ClinicOther

8. Please specify your facility type.

12. Primary Contact
14. First Name*
15. Last Name*
17. Email*
18. Phone*
20. Preferred Method of Contact*

    1. Email

    1. Phone
22. Add Secondary Contact?*

    1. Yes

    1. No
24. First Name
25. Last Name
27. Email
28. Phone
30. Preferred Method of Contact

    1. Email

    1. Phone
34. Visit Preferences
36. Visit Type*

    1. On-site ICAR
    2. Tele-ICAR
37. Length of Visit*
    -- Select One --30 minutes1 hour (standard)90 minutesOther
38. Specify your preferred length of visit
42. Visit Focus
44. -- Select One --General Infection Prevention & Control (Full ICAR)Topic-Specific ICAR (check all that apply)
46. Check all topics that apply

    1. Hand Hygiene
    2. PPE Use & Competency
    3. Environmental Services (Cleaning & Disinfection)
    4. Auditing & Competency Monitoring
    5. Emergency Preparedness
    6. Antimicrobial Stewardship & Awareness

    1. Injection Safety
    2. Transmission-Based Precautions / Enhanced Barrier Precautions
    3. Occupational Health & Staff Management / Education
    4. Outbreak Management
    5. Policy Review & Updates
50. Additional Information
52. Have you had an ICAR in the past 12 months?*

    1. Yes
    2. No
54. Is there anything specific you'd like us to know before the visit?
56. Any specific questions or concerns?
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field