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Please select all Behavioral Health Programs that apply to your facility:
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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)
How many cesarean sections (previous 12 months)?
How many vaginal births after c-section (VBACs) (previous 12 months)?
Is continuous electronic fetal monitoring performed on all patients in active labor?
If no, please explain:
Do nurse midwives practice at your hospital?
Is the facility a regional referral center for high risk pregnancies or newborns requiring intensive care?
If no, does a written procedure exist for transferring all high-risk mothers and/or babies which the hospital is not qualified to treat?
Level I: Well baby
Well Baby/Number of bassinets:
Level II: Intermediate care
Intermediate Care/Number of bassinets:
Level III: Neonatal intensive care
Neonatal/Number of bassinets:
Sex change operations
Weight reduction surgery
Laser assisted surgery
Are "scope" surgical procedures routinely videotaped?
Employed Physicians
Outside Surgeons
Residents
Are sponge, needle and instrument counts performed in the course of a surgical procedure?
If yes, at what intervals of operation?
Neurosurgery
Experimental surgery
Interns
Does the facility utilize the unit dose system of dispensing medicine?
Is the pharmacy for patient use only?
If No, annual receipts for non-patients medications are:
Is the pharmacy staffed by a contract group?
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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