NN/LM PSR E-Licensing Program: Institutional Data Form

Fields marked with a red asterisk (*) are required. Please fill in as much information as possible.

You will need to complete this form to become a SCELC–NN/LM Affiliate so that you can participate in the NN/LM PSR E-Licensing Program. You will find a complete description of this program, including instructions for signing up, at http://nnlm.gov/psr/services/e_license/program.html. For questions, call Julie Kwan at (310) 825‑5342 or call the Regional Medical Library office at (310) 825‑1200.

Institution Address

Name of Institution: *

Name of Library: *

Address: *

Address Line 2:

City: *

State: *

ZIP Code: *

LIBID: *

Billing Address

Please indicate billing address if different from above.

Accounts Payable Contact Name:

If different from Contact Person

Billing Address:

Billing Address Line 2:

Billing City:

Billing State:

Billing ZIP Code:

Billing Cycle: *

Annual

Semiannual

indicate how frequently you want to be billed

Contact Person

Name: *

Title: *

Phone: *

Fax: *

E-mail: *

a copy of this submission will be sent to this address

IT Infrastructure

Number of Physically Separate Clinics: *

IP Address Ranges: *

Resources Budget

Print Resources: * $

Electronic Resources: * $

Total Materials Budget: * $

FTE

Include full-time equivalents of part-time personnel.

Physicians: *

Nurses: *

Library Professionals: *

Library Staff: *

Accreditation

ACGME: *

Yes

Magnet Status: *

Yes

Other: *

Degree Programs: *

Hospital Data

The definitions for the following were taken from the 2008 AHA Guide. If the AHA Guide is not readily available to you, PSRML staff will add this data for you.

Staffed Beds: *

Admissions:

Census:

Births:

Comments:

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