Infection Control Plan 2022

Infection Control Plan 2022

Please complete this form to place your order.

Your plan will be delivered via email as quickly as we are able to complete it.

Please use proper capitalization and check all spelling before submitting this form.

Do not use "ALL CAPS" or "all lower-case" when completing the form.

Corrections due to misspellings or inaccurate information may result in additional charges up to $50.

Email delivery of your document can be expected by the end of the next business day.

Printed copies can be purchased for $25.

Order Date*

Facility Name*

Your company name (as licensing recognizes you)

ONLY ONE FACILITY PER ORDER

Facility Email Address:*

Administrator:*

PLEASE NAME THE PRIMARY ADMINSTRATOR ONLY

Infection Preventionist*

The name of who will be responsible for training the staff on Infection control & keeping the plan up to date. Use the administrator name if there is no other designee.

Facility Type*

Select

Facility License Number*

Nine digit number - Please include the "0" if it is the first number.

ONLY ONE FACILITY PER ORDER

Facility Street Address*

Facility City, State, Zip*

Local Licensing Office (City/Location)*

Please verify before providing this information. Some Licensing Office assignments have recently changed.

Facility Telephone Number*

Phone

Cell Phone

Phone

Payment & Contact Information

FEE*

Select or enter value

Payment Type

Select or enter value

Name of Cardholder (name found on card)*

Card Number*

Expiration Date*

CVC*

3 or 4 digit code on back or corner of the card

Billing Address*

Billing zip code*

Phone for any questions*

Phone

Email to use for delivery

Thank you for your order!

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