Nurseworks Facility Profile form

Nurseworks Facility Profile

FACILITY NAME:PHONE:

ADDRESS 1:

CITY:

CONTACT:

FAX:

ALTERNATIVE CONTACT:

FAX:

ADDRESS 2:

STATE:

TITLE:

MOBILE:

TITLE:

MOBILE:

ADDRESS 3:

ZIP:

PHONE: (EXT.)

EMAIL:

PHONE: (EXT.)

EMAIL:

FACILITY TYPE

POPULATION RECEIVING SERVICE

SKILLED NURSING FACILITY

HOSPITAL

PRIVATE SCHOOL

SCHOOL DISTRICT

ADULT DAY CARE

PRIVATE PRACTICE

GROUP HOME/RESIDENCE

HOME CARE ADULT

BED SIZE:

POPULATION:

# OF CONSUMERS:

# OF PATIENTS:

# OF RESIDENTS:

# OF CONSUMERS:

CURRENT NURSING VENDOR(S)

HOW LONG?

CURRENT STAFFING PATTERN:PLEASE ENTER HOW MANY OF EACH YOU CURRENTLY HAVE:

RNS

LPNS

RN SUP

MDS COORDINATOR

NEW STAFFING:PLEASE ENTER HOW MANY OF EACH YOU NEED TO MAKE YOUR PROGRAM A SUCCESS:

RNS

LPNS

RN SUP

MDS COORDINATOR

WHY ARE YOU DISSATISFIED WITH YOUR CURRENT PROVIDER(S)

WHAT MUST NURSEWORKS DO TO BE SELECTED AS YOUR NEW REHAB PROVIDER?

HOW DID YOU HEAR ABOUT NURSEWORKS?

WORD OF MOUTH

TRADE SHOW/SEMINAR

CLIENT REFERRAL (ALREADY WORKING WITH NURSEWORKS)

INTERNET

NURSING REFERRAL

VTA-NURSEWORKS WEBSITE

SPACE ADVERTISING

TELEMARKETING

DIRECT MAIL (FLYER/BROCHURE/POST CARD)

1901 Emmons Ave, Suite 200, Brooklyn, NY 11235

Phone: 718.615.0049 • Toll Free: 800.874.3469 • VTA Fax: 718.615.1972 • NurseWorks Fax: 718.646.5315