Program ApplicationTerms and Conditions

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C. Pharmacy Expertise

i. Training completed by pharmacist lead (check all that apply)

ii. Certificates or documentation for AS training

iii. Optional: Additional qualification details of pharmacist lead (100 words or less)

D. Action
i. Provide AS Policy

ii. Provide three AS guidelines, one of which must be for IV to PO interchange.

Two additional guidelines for a total of five may be included.

iii. Supporting documentation of antibiotic stewardship interventions that improve patient outcomes and current DAILY stewardship activities

iv. Example of ONE major initiative that resulted in program identifying a problem and implementing a solution to improve antimicrobial prescribing within the last 3 years.

IMPORTANT: Example should link CDC AS core elements of action, tracking, reporting, and education, and include supporting documentation with graphs or tables.
(500 words or less)

Supporting documentation

v. Optional Information (not required for designation)
Describe three to five unique or novel ways your stewardship program has improved antibiotic prescribing, antibiotic-associated outcomes, or diagnostic stewardship.
(500 words or less)

One example of an antimicrobial stewardship intervention that involves other clinical pharmacists or pharmacy staff in implementation.

Part 3: Optional Additional Information

i. Documentation of involvement in educational efforts regarding antimicrobial usage/stewardship on a national level.

ii. Stewardship-related publications within the last 2 years (citations only)

iii. Stewardship collaborations in the last 3 years

iv. AS regional and national oral or abstract presentations within the last 2 years

v. AS-related research grants within the last 2 years

vi. Novel approaches to AS

vii. Additional documents to support application

Part 4: Terms and Conditions

By signing below, I acknowledge and agree that I am authorized as a representative of the Hospital submitting this application to accept the following terms and conditions, on behalf of the Hospital, for participation in the Antimicrobial Stewardship Centers of Excellence ("Program"):

Participation and designation by IDSA as an “Antimicrobial Stewardship Center of Excellence” is subject to Hospital’s compliance with all applicable laws and IDSA policies, including specifically those policies related to the Program.

IDSA is the sole owner of all rights, title, and interest in and to IDSA’s name and trademarks, including the IDSA “Antimicrobial Stewardship Center of Excellence” designation, for which a limited, revocable, non-assignable license will be granted to Hospital for use, only upon the prior review and approval of IDSA, and subject to the terms and conditions of the Program.

The Hospital shall pay a non-refundable license fee of five thousand dollars ($5,000.00) with each approved initial or renewal application for participation in the Program.

The limited license herein and related fee will be valid for two (2) years starting with the date listed on the Program designation letter and certificate provided by IDSA and will expire at the end of the two (2) year period. Hospital’s use of the limited license must cease following expiration or termination of Hospital’s participation in the Program.

IDSA will list the Hospital’s name on its public website list of Antimicrobial Stewardship Centers of Excellence.

Neither IDSA nor the Hospital may disclose any Confidential Information of the other that was acquired in the course of Hospital’s application to or participation in the Program, except as permitted by the other party or under compulsion of law. "Confidential Information" means any information that is not generally available to the public.

Any notices or communications required for the license shall be in writing via electronic mail to the contact person(s) designated by IDSA and Hospital and shall become effective upon receipt unless the recipient responds otherwise.

IDSA may terminate Hospital’s participation in the Program for the Hospital’s breach of 1) these Terms and Conditions; or 2) any other applicable requirements or obligations under the Program upon written notice and Hospital’s failure to cure such breach within ten (10) days of the written notice.

Hospital Name

Name of hospital representative

Title

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