NSQHS Standards Exemplar Practice Nomination Form

This form is to be used by accrediting agencies when nominating health service organisations for exemplar practice following their accreditation assessment.

Accrediting agency details

Name of accrediting agency

Accrediting agency contact name

Email address

Phone number

Date nomination form submitted

Nominated health service organisation details

Nominated health service organisation

Address (Location)

State/Territory

Postcode

Health service organisation unique ID

Confirmation of accreditation

Ticking the box confirms that the health service organisation has been awarded accreditation to the NSQHS Standards (2nd ed.) with all actions rated as 'met'.

Date accreditation awarded

Provide the date the health service organisation was awarded accreditation.

Details of nominated exemplar practice

Summary of exemplar practice

Provide a brief description of the exemplar practice at the health service organisation you are nominating (approx. 300 words).

Clinical area(s) where exemplar practice was identified

Provide a brief description of the clinical area within the health service organisation where the exemplar practice was identified.

NSQHS Standard

Indicate the relevant NSQHS Standard the exemplar practice relates to.

Additional NSQHS Standards

List relevant standards if more than one

Action numbers

List the relevant action numbers the exemplar practice relates to.

Name of responsible officer for exemplar practice at health service organisation

Position title

Email address

Phone number

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