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Acute Care Facility Benchmarking Program
Registration Form

Facility Name

Type of Facility

Facility address

Facility City, State, Zip

1. Who will be entering data for this facility? (Limit one person per facility. This person also has access to all comparisons and reports for the facility.)

Full name

E-mail Address

Phone number

2. In addition to the person above, who should have access to see the data and reports for this facility? (List all people in your organization who should have read-only access to your facility benchmarking data.)

Full Name

E-mail address

Full Name

E-mail address

Full Name

E-mail address

Full Name

E-mail address

3. Name, e-mail, and phone number of the person completing this form:

Full Name

E-mail address

Phone number