Number of airborne infection isolation (AII) rooms _____
Number of isolation beds _____
Number of infectious disease physicians _____
Number of infection control practitioners _____
Hospital 24-hour phone number _____
Number of ICU nurses _____
Number of ICU beds _____
Number of critical care physicians _____
Number of critical care nurses _____
Does hospital have a relationship with EMS that will require a separate MOA?
Yes _ No _
EMS Contact Name ______________________________________
EMS Telephone ______________________________________
EMS Email ______________________________________
On behalf of the hospital/healthcare facility named below, I certify that we are in full compliance with the Preparedness Standards as outlined in Appendix I. [signature]
SOURCE: Centers for Disease Control and Prevention, 2004.