Annual Facility Questionnaires

SCHEDULE FOR CALENDAR YEAR 2020 DATA COLLECTION

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


ANNUAL END-STAGE RENAL DIALYSIS (ESRD) FACILITY SURVEY

 Distribution Date: February 5, 2021
 Due Date for Return of Completed Form: March 31, 2021

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 10, 2021
 Due Date for Reruen of Completed Form: April 2, 2021

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 Mike Mitchell at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov


ANNUAL HOSPITAL QUESTIONNAIRE

 Distribution Date: February 23, 2021
 Due Date for Return of Completed Form:  April 30, 2021

To download Annual Hospital Questionnaire forms:

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


ANNUAL LONG-TERM CARE FACILITY QUESTIONNAIRE

 Distribution Date: TBA
 Updated Due Date for Completion: TBA


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

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