<p> Invoice</p><p>Name:______Facility: ______Address: ______City:______State:_____ Zip:______</p><p>Amount </p><p>SGNA Infection Prevention Champions Program Two Year AIM Program: $325.00</p><p>Amount Due: $325.00</p><p>Make check payable to SGNA and mail to: SGNA Publications 8294 Solutions Center Chicago, IL 60677-8002.</p><p>If you have any questions, contact SGNA Headquarters at 800/245-7462. Primary Contact Information *Required Fields</p><p>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. </p><p>Department/Unit: Click here to enter text. *Department/Unit: </p><p>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.</p><p>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</p><p>Works at least part-time in GI/endoscopy:</p><p>Has good communication skills: </p><p>Possesses leadership skills:</p><p>Can take action when necessary:</p><p>Is accountable/credible:</p><p>Is a team player:</p><p>Has the ability to educate others: Has read and agrees with outlined Champion Job Description:</p><p>Is knowledgeable of guidelines/position statements included in toolkit:</p><p>Has access to a computer and basic word processing, e-mail and computer skills:</p><p>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. </p><p>Has completed the SGNA Associates (GTS) Program, the Advanced Associates (AGTS) Program or has the CFER certification</p><p>By submitting this application you attest that all information is accurate and truthful. If found otherwise, you are subject to disqualification from this program. </p><p>Application Components</p><p>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.</p>