IMPACT Application 
Answer the following questions to be considered to participate in the IMPACT Program. 
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Email *
Applicant's Name  (First and Last Name) *
Applicant's Phone Number *
Applicant's Position Title *
Applicant's Education/Licensure/Credentials *
Applicant's amount of experience in this position  *
Have you completed a specialized training course in the last two years? If yes, what is the name of the specialized training course? *
Do you have a nationally recognized credential in infection control? If yes, choose certification type below. *
Do you have access to a computer and internet service to attend virtual activities? *
Do you have experience using and you are able to access the following software programs at work? *
Required
Are you able to participate in the IMPACT Program's activities in person and online for 12 consecutive months?  *
List 3 IPC goals for your career growth as an IP that participation in the IMPACT Mentor Program will help you to achieve. *
Facility Name *
Facility Address *
Facility Phone Number: *
Facility Type:  *
Administrator's Name *
Administrator's Email Address *
Does your facility offer an orientation specific to the Infection Preventionist role? *
Does your facility have access to additional IPC Expertise within your organization? *
If IPC Expertise is available within your organization, please provide the following information, if available:  Name, Title, Email address and phone number. 
Does your facility have readily available access to external IPC expertise? *
If IPC Expertise is available outside of your organization, please provide the following information, if available:  Name, Title, Email address and phone number. 
List three IPC goals of your facility that participation in the IMPACT Mentor Program will help you to achieve. *
A copy of your responses will be emailed to the address you provided.
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