Enrollment Form

Complete one application for each hospital. Facilities with multiple campuses must complete one application for each campus. If you would like a copy of NDNQI's facility definition(s), please email NDNQI-Enrollment@pressganey.com.

Note: Please have all information ready before starting this form. You will not be able to save a partially completed form for later submission. Print a copy of this form.

If you have questions about enrolling, please contact NDNQI-Enrollment@pressganey.com or (855) 304-9788.

Official Name of Facility *:
Physical Address of Facility *: (Street, City, State, Zipcode)
NDNQI Participation Start Date
Start Year *:
Start Quarter *:


Previously an NDNQI Member? *:
If yes, list facility code:
American Hospital Association (AHA) Number *:
National Provider Identifier (NPI) *: (Required if Medicare accepted)
Medicare Number *: (Required if Medicare accepted)
CalNOC Participant ID *: (If applicable)
Type of Facility *:
If other, please specify:
Bed Size

Please indicate the census based on acute beds for the entire facility, including bassinets, acute rehabilitation, and acute psychiatric beds if those services are offered. Do not include sub-acute beds such as skilled nursing beds and long term care (nursing home beds).

Highest 1 day census in the past 12 months:
Average daily census (ADC) for the most recent quarter:

Ownership *:
Teaching Status *:
ASC Specialty (mark all that apply) *:
Number of Annual Procedures *:
ASC Ownership *:
Affiliated with Acute Care Hospital? *:
If yes:
National Provider Identification (NPI) for affiliated hospital:

NDNQI Hosp Code (if available):
Magnet Status *:
Magnet Designation Start Date:
Magnet Designation End Date:
ANCC Pathway to Excellence status:
If your facility has received ANCC Pathway to Excellence designation, what was your original designation year?:
Facility System: (If this facility is part of a local, regional, or national multi-facility system, list all)
NDNQI Site Coordinator (Primary Contact Person)
Name *:
Job Title *:
Department:
Phone *:
E-mail Address *:
Fax:
Complete Mailing Address *:

CNO or Executive (If other than Site Coordinator) Name: Job Title: Phone: E-mail Address: Complete Mailing Address:

How did you hear about NDNQI:
If other, please specify:
What was the single most important factor in your decision to join NDNQI?:
If other, please specify: