SCHEDULE FOR CALENDAR YEAR 2021 DATA COLLECTION
QUESTIONS: CALL 217-782-3516 or EMAIL DPH.FacilitySurvey@illinois.gov
ANNUAL END-STAGE RENAL DIALYSIS (ESRD) FACILITY SURVEY
Distribution Date: February 7, 2022
Due Date for Return of Completed Form: March 25, 2022
If you need a blank copy of the Annual ESRD Questionnaire, please Click Here
If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov
ANNUAL AMBULATORY SURGICAL CENTER QUESTIONNAIRE
Distribution Date: February 18, 2022
Due Date for Return of Completed Form: April 1, 2022
Blank Copy of Annual ASTC Questionnaire Form - Click Here
Blank Copy of ASTC Patient Origin Reporting Spreadsheet - Click Here
If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov
ANNUAL HOSPITAL QUESTIONNAIRE
Distribution Date: February 25, 2022
Due Date for Return of Completed Form: April 15, 2022
To download Annual Hospital Questionnaire forms:
Annual Hospital Questionnaire Form - Hospitals with Over 100 Authorized Beds Click Here
Annual Hospital Questionnaire Form - Hospitals with Up to 100 Authorized Beds Click Here
If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov
ANNUAL LONG-TERM CARE FACILITY QUESTIONNAIRE
Distribution Date: March 11, 2022
Updated Due Date for Completion: April 30, 2022
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 stand-alone Facilities with Nursing Care and/or Sheltered Care beds
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 Facilities with more than 16 beds for Intermediate Care for Developmentally Disabled
If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov
