Additional Sites Application - Expansion site(s)

Application Information  
Signature Statement signed by
Name:
Title:
Phone:
Reporting Period
Start Date:
End Date:
Paper Audit Item(s) and Misc. Documentation This lists the files you may need
❑ A formal description of CQI process and current project
❑ Documentation of annual program review and/or plan and advisory committee activities
❑ A copy of a de-identified patient chart showing complete education process
❑ A copy of a full section of Program's "Nutrition" curriculum
❑ A copy of a full section of Program's "Medication" curriculum
❑ A copy of a full section of Program's "Goals Setting and Behavior Change" curriculum
❑ Support Documentation
Expansion Site - Site Information Complete this information once for each expansion site included in the application
Site Name and Contact Information:
Name:
Phone:
Fax:
Add 1:
Add 2:
Service Area
What is the service area around this site considered:
❍ Urban ❍ Rural ❍ Suburban
Expansion Site Information
There is evidence to show that each of the following items is the SAME at the expansion site as it is at the site from which you are expanding:
❑ Curriculum
❑ At least one instructor who is RN, RD or pharmacist
❑ Instructors who have the academic credentials to sit for the CDCES exam
❑ Instructors are CDCES, BC-ADM or have CEU's in the past 12 months
❑ Continuous Quality Improvement Process and Current Project
❑ Policies and Procedures
❑ Educational Chart Forms