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 _____

EMS Services

Does hospital have a relationship with EMS that will require a separate MOA?

Yes _ No _

If yes,

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.