RALS-Annual Report

Complimentary POC Glucose Report for RALS-Plus Users

As a RALS-Plus user, you now have the ability to compare your hospital’s mean glucose results to hospitals across the country participating in the RALS-Annual Report program. Once you’ve signed up, you’ll receive an access and subscription agreement that must be signed by the appropriate person within your hospital. After we get this signed agreement, you will receive the RALS-Annual Report every year that you remain a RALS-Plus user! Thank you in advance for participating in this value-added service. If you are part of a multi-hospital system, please complete a submission form for each institution.

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Name:
Title:
Health System Name:
Hospital Name you would like to see on your Report: (please do not abbreviate)
Total # of Beds:
(please provide # of staffed beds, not licensed beds)
ICU Name:
 (as listed in the location’s page of RALS-Plus - if none, enter 'NONE' in the first box)
NICU, Nursery,
or Pediatric name:
(to be excluded from the report - if none, enter 'NONE' in the first box)
List of locations
using TGC protocols:
(as listed in the RALS-Plus locations page)
Address:
(please indicate the actual address of the hospital receiving the report)
City:
State:
Zip
Email Address:
Telephone:
Fax:
Hospital Type: Academic
(One of the 400 teaching members of the AAMC which are defined as “Not-for-profit teaching hospitals in the U.S. and Canada are eligible if they are affiliated with a medical school member and offer residency programs in at least four specialties)
 Urban Community
 Rural Community
GPO:
(If you are affiliated with a GPO, please identify your organization) 		Adventist, Inc.
 Healthways Inc.
 Novation, LLC
 Premier, Inc.
 Veterans Health Administration
 None
Healthcare Provider:
(If you are affiliated with a specific Healthcare Provider, please identify your organization - choose one only) 		Community Health Systems
 HCA, Hospital Corporation of AmericaTenet Healthcare Corporation
 Universal Health Services
 University Health System Consortium
 None