To have a member of our team contact you, please take a few minutes to tell us more about your organization.
Name
Type of Organization Individual Educational A Hospital Other
Country United States Canada Other
Address 1
Address 2
City
State/Province AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Postal Code
Title Dr. Mr. Ms.
First Name
Last Name
Credentials
Phone
Fax
E-Mail
Is your facility part of a health system? yes no
What is the name?
How did you hear about NICHE? A colleague National Nurse Staff Developers Organization (NNSDO) University or Educational Setting A HospitalThe Hartford Institute Website Web search Non-NICHE Website (please specify)Voice (AONE) The Journal of Nursing Administration (JONA) MEDSURG Nursing NICHE brochure - direct mail Other advertisement (please specify)American Journal of Nursing (AJN) The Joint Commission: The Source Advance for Nurses magazine Other article (please specify)ANCC Magnet Conference Non-NICHE conference or event (please specify)Other (please specify)
Please specify:
Number of staffed beds:
Do you have a geriatric medical department? yes no
Do you have a geriatric services line? Yes No I don't know
Do you have geriatricians? yes no
how many?
Do you have geriatric nurse practitioners? yes no
Do you have clinical nurse specialists? yes no
Do you have an Acute Care for the Elderly (ACE) unit? yes no
Do you have a HELP program? yes no
Do you have a Transitions model? yes no
Do you have other geriatric initiatives? yes no
Please describe:
Magnet status: No Plans to Apply Intend to Apply In Process of Applying Magnet Recognition Achieved Unsuccessful Application Former Magnet Site
What percentage of patients in your hospital are over age 65? %
Who would be working with you on this program? List their names and roles:
Has hospital administration identified a need for a geriatric program? yes no
Choose the highest level of administrative support:Chief Nursing Officer Executive Level (Other than CNO) Departmental/Service Line Management Unit Level Management Other
List three reasons why your hospital is interested in implementing NICHE:
What non-geriatric strategic initiatives is your hospital planning or implementing at present?
