Statement of Account

Invoice

Name:______Facility: ______Address: ______City:______State:_____ Zip:______

Amount

SGNA Infection Prevention Champions Program Two Year AIM Program: $325.00

Amount Due: $325.00

Make check payable to SGNA and mail to: SGNA Publications 8294 Solutions Center Chicago, IL 60677-8002.

If you have any questions, contact SGNA Headquarters at 800/245-7462. Primary Contact Information *Required Fields

Facility: Click here to enter text. *Official Facility Name: Click here to enter text. *Facility Address 1: Click here to enter text. Facility Address 2: Click here to enter text. *Facility City: Click here to enter text. *Facility State: *Facility Zip: Click here to enter text.

Department/Unit: Click here to enter text. *Department/Unit:

Click here to enter text. *Manger/Contact First Name: Click here to enter text. *Manger/Contact Last Name: Click here to enter text. *Manger/Contact Job Title: Click here to enter text. *Manger/Contact Work Phone: Click here to enter text. *Manger/Contact Preferred E-mail: Click here to enter text. *Recommended Champion First Name: Click here to enter text. *Recommended Champion Last Name: Click here to enter text. Recommended Champion Credentials: Click here to enter text. *Recommended Champion Job Title: Click here to enter text. *Recommended Champion Length in Current Position: Click here to enter text. *Recommended Champion Work Phone: Click here to enter text. Recommended Champion Home/Mobile Phone: *Recommended Champion Preferred E-mail: Click here to enter text.

Manager/Contact to complete and verify Champion Criteria Checklist: Note: A Champion must be able to fulfill all of the below requirements to become a Champion. Champion is a: Nurse Technician

Works at least part-time in GI/endoscopy:

Has good communication skills:

Possesses leadership skills:

Can take action when necessary:

Is accountable/credible:

Is a team player:

Has the ability to educate others: Has read and agrees with outlined Champion Job Description:

Is knowledgeable of guidelines/position statements included in toolkit:

Has access to a computer and basic word processing, e-mail and computer skills:

Has made contact with facility’s Infection Control Committee or similar group: Click here to enter text. *Name of Representative: *Representative e-mail: Click here to enter text.

Has completed the SGNA Associates (GTS) Program, the Advanced Associates (AGTS) Program or has the CFER certification

By submitting this application you attest that all information is accurate and truthful. If found otherwise, you are subject to disqualification from this program.

Application Components

Please attach the GTS, AGTS or CFER Certificate with the mailing of the application, invoice and check in order to be considered for the program.