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Profile and Scope of Services Inquiry Form
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Profile and Scope of Services Inquiry Form
PART 1 – FACILITY INFORMATION
A. Basic Facility Data
Facility Legal Name
Brand / Common Name (if different)
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre & Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Website
Phone
Ownership Entity
Select
Company
Group
Ownership Type
Governmental
Private Non Gov
Military
Police
Other
Facility Type
Acute Care Hospital
Specialty Hospital
Ambulatory Center
Rehabilitation
Other
Other Ownership Type
Other Facility Type
Academic Medical Center?
Select
Yes
No
Primary Counterpart
Name
Title
Email Address
Direct Tel
Fax
B. Executive Contacts
Chief Executive Officer
Name
Title
Email Address
Direct Tel
Fax
Chief Medical Officer
Name
Title
Email Address
Direct Tel
Fax
Executive Director / COO
Name
Title
Email Address
Direct Tel
Fax
Quality & Patient Safety Director
Name
Title
Email Address
Direct Tel
Fax
C. Service Portfolio – (Please complete or tick as appropriate)
Check all clinical and support services.
Add numbers or notes in the grey fields.
Inpatient & Critical Care
Medical / Surgical Inpatient
Number Of Beds
Key Sub Specialties or Notes
Adult Intensive Care / Critical Care
Number Of Beds
Key Sub Specialties or Notes
Neonatal ICU (NICU)
Number Of Beds
Key Sub Specialties or Notes
Pediatric ICU / Pediatric Ward
Number Of Beds
Key Sub Specialties or Notes
Women & Children
Obstetrics (LDRP)
Number Of Beds
Key Sub Specialties or Notes
Gynecology
Number Of Beds
Key Sub Specialties or Notes
Well Baby Nursery
Number Of Bassinets
Key Sub Specialties or Notes
Peri Operative & Procedural
Operating Theatres
Number Of Rooms
Key Sub Specialties or Notes
Hybrid ORs
Robotic
Cath Laboratories
Number Of Rooms
Key Sub Specialties or Notes
Endoscopy / Day Surgery Suites
Number Of Rooms
Key Sub Specialties or Notes
Post Anaesthesia / Recovery
Number Of Bays
Key Sub Specialties or Notes
Emergency & Urgent Care
Adult Emergency Dept.
Number Of Beds
Key Sub Specialties or Notes
Resus
Isolation
Pediatric Emergency Dept.
Number Of Beds
Key Sub Specialties or Notes
Trauma Center
Level
Number of centers
Key Sub Specialties or Notes
Medical & Surgical Sub Specialties (tick each service that will have dedicated wards / clinics)
Cardiology & Cardiothoracic Surgery
Number Of Wards
Number Of ICUs
Key Sub Specialties or Notes
Hybrid OR
Neurology, Stroke, Spine & Neurosurgery
Number Of Wards
Number Of ICUs
Key Sub Specialties or Notes
Gamma Knife
Orthopaedic Surgery
Number Of Beds
Key Sub Specialties or Notes
Organ Transplant
Number Of Wards
Number Of ICUs
Key Sub Specialties or Notes
Kidney
Liver
Other
Robotic / Minimally Invasive Surgery
Number Of Beds
Key Sub Specialties or Notes
Urology
GI
Other
Oncology – Medical / Surgical / Radiation
Number Of Beds
Key Sub Specialties or Notes
LINAC
PET
Internal Medicine (specify)
Number Of Beds
Key Sub Specialties or Notes
Cardio
GI
Renal
Other
Ophthalmology, Maxillofacial & ENT
Number Of Beds
Key Sub Specialties or Notes
Psychiatry / Behavioral Health
Number Of Beds
Key Sub Specialties or Notes
Diagnostic & Therapeutic Support
Radiology (CT, MRI, X ray, IR)
CT
MRI
X ray
Key Sub Specialties or Notes
Nuclear Medicine
PET
Cyclotron
Key Sub Specialties or Notes
Radiation Therapy
LINAC
Brachy
Key Sub Specialties or Notes
Clinical Laboratory
Core
Blood Bank
Key Sub Specialties or Notes
Pharmacy (In & Out patient)
Key Sub Specialties or Notes
Central Sterile Supply Dept. (CSSD)
Key Sub Specialties or Notes
Medical Gas & Utility Systems
Key Sub Specialties or Notes
Ambulatory / Clinics
Total Planned Clinics
NO Of clinics
List key specialties
Dialysis / Renal Center
NO Of stations
Key Sub Specialties or Notes
Rehabilitation / Physio
NO of rooms
Key Sub Specialties or Notes
Infusion / Day Care
NO of chairs
Key Sub Specialties or Notes
Feel free to add rows or annotate any service not listed in the Form.
PART 2 – DETAILED DESCRIPTION
A. Inpatient Activity
Licensed Beds
Adult Med/Surg
Pediatric
ICU (all types)
Obstetric/Postpartum
Behavioral Health
Observation / Holding Beds
Expected Average Monthly Admissions
Expected Annual ER Visits
Contracted / Outsourced Clinical Services
Number
Specify
CSSD
Laundry
Catering
IT
Biomedical
Other
Specify
B. Out Patient Profile
Outpatient Departments / Units
Expected Annual Outpatient Visits
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Profile and Scope of Services Inquiry Form
