Annual Facility Questionnaires

SCHEDULE FOR CALENDAR YEAR 2017 DATA COLLECTION

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


ANNUAL END-STAGE RENAL DIALYSIS (ESRD) FACILITY SURVEY

 Distribution Date: February 2, 2018
 Due Date for Return of Completed Form: March 9, 2018

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


ANNUAL AMBULATORY SURGICAL CENTER QUESTIONNAIRE

Distribution Date: February 9, 2018
Due Date for Completion: March 16, 2018

Blank Copy of Annual ASTC Questionnaire Form - Click Here

Blank Copy of ASTC Patient Origin Reporting Form - Click Here


ANNUAL HOSPITAL BED REPORT

Distribution Date: February 16, 2018
Due Date for Completion: April 2, 2018

All hospitals should receive an Email with a link to the Annual Hospital Bed Report form for their facilty. 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 16, 2018
Due Date for Completion:  April 2, 2018

Blank Copy of Annual Hospital Questionnaire - Click Here


ANNUAL LONG-TERM CARE FACILITY QUESTIONNAIRE

Distribution Date: February 23, 2018
Due Date for Completion: April 16, 2018

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 Questionnaires:
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 Faciltiies with more than 16 beds for Intermediate Care for Developmentally Disabled


ANNUAL HOSPITAL COMMUNITY BENEFITS REPORT

Distribution Date:    TBA
Due Date for Completion:    TBA