Organization Information

Organization

Healthcare Organization Name*

PTE Number*

Type of ODF Report*

Located in Rural Location?

Healthcare Facility Street Address

City

State (2-letter abbreviation) or Province

Country

ZIP

Is this Facility Part of a Hospital System?

If Yes, Hospital System Name

Medicare Provider Number (if applicable)

AHA Hospital Number (if applicable)

Date CNO Assumed CNO Role at this Facility

Is the Nursing Staff Organized for Collective Bargaining?

Beginning Date

Ending Date

Number of Inpatient Licensed Beds - Acute Care

Number of Inpatient Licensed Beds - Long Term Care

Average Daily Census for the 12-Month Reporting Period

Average Length of Stay

Case Mix Index

Average Length of Stay Case Mix Adjusted

Average Length of Stay

Case Mix Index

Average Length of Stay Case Mix Adjusted

Annual Total Number of Patient Visits