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From where is the blood or blood product obtained?
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MedMal
Facility Business Address
Address
City
State
Zip
Mailing Address
Address
City
State
Zip
Please select any of the Facility Types that are applicable to the exposures you are reporting in this application:
Does this application include information for a Hospital or Medical Center?
Does this application include information for a Public Health Clinic or are Public Health Services provided?
Does this application include information for a Mental Health Clinic or are Mental Health services provided?
Does this application include information for a Jail, Juvenile Hall, or other Correctional Care Facilities?
Does this application include information for a School or provide Student Care Services?
Please check all the Facility Sub-Types that apply to the exposures you are reporting in this application:
General Hospital
Teaching Hospital
Medical School
Critical Access Hospital (CAH)
Children's Hospital
Geriatric Hospital
Women's Hospital
Rehabilitation Hospital
Psychiatric Hospital
Acute Psychiatric Hospital (APH)
Psychiatric Health Facility
Mental Health Crisis Stabilization Unit (CSU)
Skilled Nursing Facility
Long Term Care Facility (LTC)
Hospital Based Clinics
Ambulatory Surgery Center
Jail
Juvenile Hall
Boot Camp
Half-way House (substance abuse counselors)
Provides Inpatient Services
Provides Outpatient Services
Public Health Department
Student Health Center
Urgent Care Center
Other
Please enter a description if you have other Facility Sub-Types not listed above:
Please check all the Accreditations, Licenses, and Memberships that apply to the Facilities you are reporting in this application:
None of the below
Licensed by State
Medicare Approved
Accredited by AOA
Accredited by CARF
Elected Officials
Appointed Officials
Volunteers
Full Time Employees
Part Time Employees
Full-Time Equivalents (FTE)
Board Members
Certified
Classified
Administrative
Total Number of Employees
If the prior employee total differs from the amount provided previously by more than 10%, please provide reasons for the change.
K-8 ADA
9-12 ADA
Adult Education ADA
Total ADA
As the prior average daily attendance differs from the amount provided previously by more than 10%, please provide reasons for the change
Firefighters
Police/Sheriff
Peace Officers
Other
Other Description
Do you have events where 250+ volunteers will be working on behalf of your organization
If Yes, please provide details of the event(s)
WC Budgeted Payroll
Upload Submember Payroll
Aircraft Operation (7424)(1)
Airport Law Enforcement Officers (7720)
Airport Operator (7429)
Animal Control Officers (7720)
Bus Operators (7382)
Clerical Office (8810)
Clerical Telecommuting Employees (8871)
County Probation Officers, Group Counselors, or Juvenile Services Officers (9410)
District Attorney Inspectors (9410)
Electrical Light or Power Line Construction (7538)
Electrical Light or Power Companies (7539)
Firefighters - Regular (7706)
Harbor or Port Police Officers (7720)
Hospitals (9043)
Hospitals - veterinary (8831)(1)
Housing Authorities (9033)
Institutional (8830)
Libraries (8812)
Lifeguards (9420)
Medical Center Employees (8834)
Municipal - Non-Manual Labor (9410)
Municipal - Manual Labor (9420)
Museum Curators (8838)
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From where is the blood or blood product obtained?
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From where is the blood or blood product obtained?