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MSDH Antibiotic Stewardship Program Honor Roll Acute Care Hospital Enrollment Application

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The Mississippi State Department of Health (MSDH) is pleased to recognize healthcare facilities in Mississippi that are dedicated to improving antibiotic use, reducing antibiotic resistance, and enhancing patient outcomes through the implementation of an antibiotic stewardship program (ASP) that fulfills the Core Elements of Antibiotic Stewardship outlined by the Centers for Disease Control and Prevention (CDC).

Thank you for taking the time to apply for the Antibiotic Stewardship Program Honor Roll!

Applications are accepted on a rolling basis throughout the year. The Honor Roll is updated with new facilities once every quarter. Approved applications remain valid until the end of the calendar year in which they are awarded. Please refer to instructions on the MSDH Antibiotic Stewardship Program Honor Roll Webpage for additional information.

The MSDH ASP Honor Roll application is open to all acute care hospitals in Mississippi. Individual institutions within a healthcare system will need to apply separately to obtain designation for each facility. At this time, we are specifically accepting applications from acute care hospital antibiotic stewardship programs only. However, we plan to extend the program's scope to include skilled nursing facilities and nursing homes in the near future. All hospitals are encouraged to apply.

If you have any questions about how to apply, please contact HAIAR@msdh.ms.gov before filling out the application.

Hospital Name:
Address:	City:
State:	Zip Code:
NHSN ID or Facility ID: (optional, please ask your Infection Preventionist if not known)
Average Number of Beds:
Facility Type:

Specify Other Facility Type:

* must provide value

Name:	Title:
Email Address:	Phone Number:
Primary Role:

Specify Other Healthcare Facility Professional:

* must provide value

Name:	Title:
Email Address:	Phone Number:
Primary Role:

Alternate Specify Other Healthcare Facility Professional:

* must provide value

Which of the following positions are represented on the facility's ASP Team?

Physician

Pharmacist

Infection preventionist

Microbiology laboratory staff (required of hospitals with onsite laboratories)

Nursing staff

Information technology staff

Quality improvement staff

Other

Name of physician leader:

* must provide value

Name of pharmacist leader:

* must provide value

For inclusion in the MSDH ASP Honor Roll, please attach a letter of commitment from hospital leadership that fulfills the specified criteria below. A template letter is available to download at the link below.

The letter must include a description of how the hospital has established antibiotic stewardship as an organizational priority through support of its ASP, including provision of staffing, financial, and information technology resources.
Please upload your completed letter of commitment here

Attachment:Antibiotic Stewardship Letter of Commitment.pdf

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