Annual Facility Questionnaires

SCHEDULE FOR CALENDAR YEAR 2019 DATA COLLECTION

Due to the Covid-19 pandemic, due dates for health facilities questionnaires are waived.

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


ANNUAL END-STAGE RENAL DIALYSIS (ESRD) FACILITY SURVEY

 Distribution Date: February 7, 2020
 Due Date for Return of Completed Form: To Be Determined

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 14, 2020
Due Date for Completion: To Be Determined

Blank Copy of Annual ASTC Questionnaire Form - Click Here

Blank Copy of ASTC Patient Origin Reporting Spreadhseet - 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 21, 2020
Due Date for Completion:  To Be Determined

To download Annual Hospital Questionnaire forms:

Annual Hospital Questionnaire Form - Hospitals with Over 100 Authorized Beds    Click Here

ANNUAL HOSPITAL BED REPORT

Distribution Date: February 21, 2020
Due Date for Completion: To Be Determined


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 28, 2020
Due Date for Completion: To Be Determined


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 16 or fewer 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