Network 5's Sepsis Awareness Month Campaign

Bingo Reporting

Complete the verification below so your facility receives credit for your campaign efforts. Some spaces will need additional verification to receive credit. If we need additional information, a Network employee will contact you.

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* 1. Facility Information

Facility name

CCN (6-digit CMS certification number)

Person completing form

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* 2. How many rows have you completed on your bingo card?

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* 3. If you have scheduled an ICAR, please include date of assessment:

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* 4. Attach picture of activities or education (optional)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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