Facility ID# Permit ID# CERTIFICATION OF COMPLIANCE INSTRUCTIONS: Complete this form after all work and testing is finished at this facility under this permit.

Source URL: www.deq.mt.gov

• Construction
• Mechanical engineering
• Piping
• Architecture
• Engineering
• Active fire protection
• Plumbing
• Building engineering
• Chemical engineering

JISC Digital Repositories Programme Use Case Template Use Case Name Public Attribution Facility Use Case ID (unique identifier, used for file name also) e.g. project_use_case_id

Source URL: www.ukoln.ac.uk

• Knowledge representation
• Data modeling
• Systems Modeling Language
• Archival science
• Open access
• Repository
• Use case
• Diagram
• Software development
• Science
• Unified Modeling Language

Select the surveillance module checkbox(es) to inform CDC that those data are being collected and reported as specified by their corresponding surveillance protocol(s). *required for saving Page 1 of 1 Facility ID: _____

Source URL: www.cdc.gov

• Vaccines
• Arteriovenous fistula
• Cannula
• Renal dialysis
• Medicine
• Health
• Influenza vaccine

Pneumonia (PNEU) Page 1 of 4 *required for saving **required for completion Facility ID: Event #: *Patient ID:

Source URL: www.cdc.gov

Prevention Process Measures Monthly Monitoring for Dialysis Page 1 of 1 *required for saving **Each process measure is conditionally required based upon monitoring selection in Monthly Reporting Plan Facility ID #:____

Source URL: www.cdc.gov

• Catheters
• Nephrology
• Hemodialysis
• Dialysis catheter
• Arteriovenous fistula
• Dialysis
• Port
• Medicine
• Renal dialysis
• Membrane technology

Dialysis Patient Influenza Vaccination Denominator Page 1 of 1 *required for saving *Facility ID# *Month:

Source URL: www.cdc.gov

• Membrane technology
• Nephrology
• Influenza vaccine
• Home hemodialysis
• FluMist
• Dialysis
• Influenza
• Hemodialysis
• Peritoneal dialysis
• Medicine
• Renal dialysis
• Vaccines

UST Operator Inspection - Utah YEAR ________ Facility Name Facility ID

Source URL: deq.utah.gov

• Water
• Biology
• Human behavior
• Caving
• Hydrology
• Sump

Missouri Department of Natural Resources Water Pollution Control Branch Enforcement Case List by Facility Permit No/ID Facility Name

Source URL: www.dnr.mo.gov

New Admission Information [Facility Name]: [Survey Event ID] – [Survey Start Date] Please provide the following information for residents admitted to the facility after: Only include residents that are still residing i

Source URL: cms.gov

New Admission Information [Facility Name]: [Survey Event ID] – [Survey Start Date] Please provide the following information for residents admitted to the facility after: Only include residents that are still residing i

Source URL: www.cms.gov