ICRA Opportunity Report Form

ICRA Opportunity Report Form
ICRA Tracking and Accomplishments
Date *

Month Day Year
Date
Date Last Visited

Month Day Year
Date
Follow Up Date

Month Day Year
Date
Council *
Team Room *
Tm Rm
ICRA Lead Name *

First Name Last Name
ICRA Lead Phone *
Phone
ICRA Lead Email *
example@example.com
View/Enter Tracking Info?

Yes
Type of Facility *

Medical Pharmaceutical Higher Education
Hospital System
Name of Facility *
# of Beds
ICRA Required?
Facility Street Address *
City *
State *
Zip *
Tracking Information
New to ICRA?

Yes No
Value of Hospital/Main Campus Work
ICRA Value (Main Campus)
Signatory Contractor Awarded Main Campus Work?

Yes No
Value of Hospital/Off Campus Work
ICRA Value (Off Campus)
Signatory Contractor Awarded Off Campus Work?

Yes No
# of Union Members Trained in ICRA 24
# of Contractors Signed Because of ICRA
Actions Taken That Created a Positive Outcome
Facilities Using the 8-Hour Training
ICRA Language in Hospital Documents

Yes No
INFECTION PREVENTIONIST CONTACT:
IP

First Name Last Name
Actual Title
Phone Number
Email
example@example.com
FACILITIES DIRECTOR CONTACT:
Fac Dir

First Name Last Name
Actual Title
Phone Number
Email
example@example.com
ADDITIONAL CONTACT:
Other

First Name Last Name
Title
Phone Number
Email
example@example.com
Signatory Contractor Notes
List the names of any contractors that did work on site (include Contact Info if possible).
Non-Signatory Contractor Notes
List the names of any non-signatory contractors that did work on site (include Contact Info if possible).
Comments
Notes Regarding Visit (Include INITIALS and DATES for each visit)
# of Visits
How many times have you visited this facility? (Add 1 to the # with every visit.)
Outcome of Visit

Positive Negative Neutral
# of Man Hours Created Because of ICRA
Positive Comments About ICRA
(Includes Dates And By Whom)
Interested in Training

Yes No
Follow Up Visit Requested

Yes No
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ICRA Opportunity Report Form

ICRA Tracking and Accomplishments