Site Name and Contact Information:
Name: |
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Phone: |
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Fax: |
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Add 1: |
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Add 2: |
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Service Area
What is the service area around this site considered:
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Urban |
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Rural |
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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 |
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At least one instructor who is RN, RD or pharmacist |
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Instructors who have the academic credentials to sit for the CDCES exam |
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Instructors are CDCES, BC-ADM or have CEU's in the past 12 months |
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Continuous Quality Improvement Process and Current Project |
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Policies and Procedures |
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Educational Chart Forms |
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