Centers of Excellence for Perinatal Substance Use Application

Please complete this application for Centers of Excellence for Perinatal Substance Use. Your answers will be scored based on criteria developed by a consortium of experts in the field of perinatal health and substance use disorders. Submitted applications will be released to and reviewed for approval by the Centers of Excellence Review Committee. You will be contacted with the results. If you have any questions or comments, please contact centersofexcellence@doh.wa.gov

Question Title

* 1. Authorization, Contact Information, Team Members

I (or my designee) have reviewed the information about Centers of Excellence for Perinatal Substance Use certification and authorize my facility to submit documentation to be recognized as a Centers of Excellence for Perinatal Substance Use.

I (or my designee) do not authorize my facility to submit documentation to be recognized as a Centers of Excellence for Perinatal Substance Use.

I acknowledge and agree:

This recognition will be listed on the Washington State Department of Health’s website, and for the Washington State Department of Health to promote, recognize, and acknowledge our hospital in other ways, including social media.

The Washington State Department of Health will store our application for the next seven years, as part of the Public Records Disclosure Act of RCW 42.56. If our hospital’s information is requested per Public Disclosure Request, our facility will be notified per RCW 42.56.540 in which we have the right to challenge disclosure.

The Centers of Excellence for Perinatal Substance Use recognition is valid for three years, and our hospital will need to reapply to the program to maintain recognition as a Centers of Excellence for Perinatal Substance Use facility.

Upon application the Centers of Excellence for Perinatal Substance Use program will contact your facility for further information and may suggest changes in your hospital’s policies to be recognized as a Centers of Excellence for Perinatal Substance Use.

The Centers of Excellence for Perinatal Substance Use program reserves the right to review policies, procedures, data, and materials at any time during the three-year recognition period and change our Centers of Excellence for Perinatal Substance Use status based on review and subsequent follow up.

Question Title

* 2. I agree that the data and information in this application is accurate, to the best of our knowledge.

Hospital Name

Hospital Administrator

Administrator Signature
The signature may be electronic. The format for electronic signatures is /s/:Name

Date

Question Title

* 3. Facility Contact Information
We may need some additional information from you. Let us know who is coordinating the application for recognition.

Name

Title:

Facility Mailing
Address Line 1

Address line 2

City/Town

State/Province

ZIP/Postal Code

Webpage
We can link information and resources from your hospital on our Centers of Excellence webpage.

Email Address

Phone Number

Question Title

* 4. Application Team Members

We encourage you to put together a team of people to help with this application and process, which includes the manager or director of the maternity center. To help in our understanding who is involved in this work, please let us know the types of positions who make up your team. Check all that apply.

Family Medicine Provider

Labor & Delivery Nurse

Lactation Consultant (IBCLC)

Maternity Center Administrator or Manager

Mother-Baby Care Nurse

Social Work

Certified Nurse Midwife (CNM)

Nurse from Newborn Care

Obstetrical Provider

Pediatric Provider

Quality Improvement Coordinator

Other relevant staff (please specify)

Centers of Excellence for Perinatal Substance Use Application

Question Title

* 1. Authorization, Contact Information, Team Members

Question Title

* 2. I agree that the data and information in this application is accurate, to the best of our knowledge.

Question Title

* 3. Facility Contact InformationWe may need some additional information from you. Let us know who is coordinating the application for recognition.

Question Title

* 3. Facility Contact Information
We may need some additional information from you. Let us know who is coordinating the application for recognition.