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Center Awards
FAQ’s
EHR Portal
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Center Awards Application
Wound Program of Excellence
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Step
1
of
8
12%
Is your facility currently contracted with Wound Care Specialists?
*
Yes
No
If your facility is not currently contracted with Wound Care Specialists, you will not be able to proceed with this application.
Facility Name:
*
Street Address:
*
City:
*
State:
*
Zip Code:
*
Administrator’s Full Name:
*
Administrator Email
*
Director of Nursing Services’ Full Name:
*
DNS Email:
*
Wound Nurse’s Full Name:
*
Wound Nurse Email:
*
This field is hidden when viewing the form
Title:
*
This field is hidden when viewing the form
Email address:
*
Name of Wound Care Specialists provider:
*
Does your facility have a full-time wound nurse that rounds weekly with a provider from Wound Care Specialists?
*
Yes
No
Does your facility have a dedicated wound nurse that rounds weekly with a provider from Wound Care Specialists?
*
Yes
No
What wound healing treatment modalities are being utilized by your facility’s PT/OT department?
*
CPI
Diathermy
ESTIM
None
Is there a registered dietician on staff at your facility?
*
Yes
No
Are wound outcome reports reviewed at quarterly medical staff meetings?
*
Yes
No
Consent
*
I attest to the accuracy of the information in this application.
Full name of person submitting application request:
*
