Annual Facility Questionnaires

SCHEDULE FOR CALENDAR YEAR 2018 DATA COLLECTION

QUESTIONS: CALL 217-782-3516 or EMAIL DPH.FacilitySurvey@illinois.gov


ANNUAL END-STAGE RENAL DIALYSIS (ESRD) FACILITY SURVEY

 Distribution Date: February 1, 2019
 Due Date for Return of Completed Form: March 8, 2019

If you need a blank copy of the Annual ESRD Questionnaire, please Click Here

If you have any questions or problems, please contact Mike Mitchell at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov


ANNUAL AMBULATORY SURGICAL CENTER QUESTIONNAIRE

Distribution Date: February 8, 2019
Due Date for Completion: March 15, 2019

Blank Copy of Annual ASTC Questionnaire Form - Click Here

Blank Copy of ASTC Patient Origin Reporting Form - Click Here

If you have any questions or problems, please contact Mike Mitchell at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov


ANNUAL HOSPITAL QUESTIONNAIRE

Distribution Date: February 15, 2019
Due Date for Completion:  April 5, 2019

To download Annual Hospital Questionnaire forms:

Annual Hospital Questionnaire Form - Hospitals with 100+ Beds    Click Here

ANNUAL HOSPITAL BED REPORT

Distribution Date: February 15, 2019
Due Date for Completion: April 5, 2019

All hospitals should receive an Email with a link to the Annual Hospital Bed Report form for their facility. If you have any questions or problems, please contact Mike Mitchell at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov


ANNUAL LONG-TERM CARE FACILITY QUESTIONNAIRE

Distribution Date: February 22, 2019
Due Date for Completion: April 19, 2019

All Long-Term Care (LTC) facilities should receive an email notification of the questionnaire with the appropriate form for their facility type and directions for the completion and submission of the form

Long-Term Care (LTC) Facility Questionnaire Forms:
Form for Hospital-based Skilled Nursing Units

Form for Facilities with Skilled <22 beds for Developmentally Disabled

Form for Facilities with less than 16 beds for Intermediate Care for Developmentally Disabled

Form for stand-alone Facilities with Nursing Care and/or Sheltered Care beds

Form for Facilities with more than 16 beds for Intermediate Care for Developmentally Disabled


ANNUAL HOSPITAL COMMUNITY BENEFITS REPORT

Distribution Date:    TBA
Due Date for Completion:    TBA