Annual Facility Questionnaires

QUESTIONS: CALL 217-782-3516 or EMAIL DPH.FacilitySurvey@illinois.gov

 Distribution Date: January 2, 2024
 Due Date for Return of Completed Form: April 1, 2024

Blank copy of the Annual ESRD Questionnaire

If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov

 Distribution Date: January 2, 2024
 Due Date for Return of Completed Form: April 1, 2024

Blank Copy of Annual ASTC Questionnaire Form

Blank Copy of ASTC Patient Origin Reporting Spreadsheet

If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov

 Distribution Date: January 2, 2024
 Due Date for Return of Completed Form:  April 15, 2024

To download Annual Hospital Questionnaire forms:

Annual Hospital Questionnaire Form - Hospitals with Over 100 Authorized Beds

Annual Hospital Questionnaire Form - Hospitals with Up to 100 Authorized Beds

If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov

 Distribution Date: January 2, 2024
 Updated Due Date for Completion: April 30, 2024

All Long-Term Care (LTC) facilities should receive an email notification of the questionnaire with the appropriate form for their facility type and directions for the completion and submission of the form

Long-Term Care (LTC) Facility Questionnaire Forms:
Form for Hospital-based Skilled Nursing Units

Form for stand-alone Facilities with Nursing Care and/or Sheltered Care beds

Form for Facilities with Skilled <22 beds for Developmentally Disabled

Form for Facilities with 16 or fewer beds for Intermediate Care for Developmentally Disabled

Form for Facilities with more than 16 beds for Intermediate Care for Developmentally Disabled

If you have any questions or problems, please contact us at 217-782-3516 or send Email to DPH.FacilitySurvey@illinois.gov