Dear Nursing Home Administrator:

The Department of Health is requesting your assistance in the development of an up-to-date database of all individuals responsible for the governance of nursing homes in New York State. Please note that the information you provide in this survey must be accurate and correspond with the information reported to the Centers for Medicare and Medicaid Services, the Department of State�s Charities Bureau in your facility�s annual 990, and/or any other state or federal agency.  

Directions
All nursing home facilities must complete questions 1-5.

Not-for-profit Nursing Homes
Please provide the name and contact information (professional email address and phone number) of your Board of Director's President and all Board members.

For-profit Nursing Homes
Please provide contact information for individuals possessing an ownership interest in your nursing home.

Please complete the survey no later than Friday, June 5, 2020 at 3:00 p.m.

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* 1. Please indicate the name of your facility.

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* 2. Please indicate your facility's permanent facility identifier (PFI) number.

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* 3. Please indicate your Administrator's name.

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* 4. Please indicate your Administrator's email address.

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* 5. Please indicate your Administrator's phone number.

If your nursing home is a not-for-profit facility, please answer the following questions regarding your Board President's contact information.

If your facility is a for-profit facility, please skip to Question 20.

* Please note that Board information should be reviewed and updated no less than quarterly and more frequently when changes to the governing authority are made.

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* 6. Please indicate your Board President's name.

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* 7. Please indicate your Board President's employer (if applicable).

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* 8. Please indicate your Board President's professional email address. 

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* 9. Please indicate your Board President's 24/7 phone number.

If your facility is a not-for-profit facility, please list all current Board members. Please note that you can upload a file list of the Board members at the end of the survey (Question 31) instead of listing them individually below.

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* 10. Board member name and title (if applicable).

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* 11. Board member name and title (if applicable).

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* 12. Board member name and title (if applicable).

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* 13. Board member name and title (if applicable).

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* 14. Board member name and title (if applicable).

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* 15. Board member name and title (if applicable).

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* 16. Board member name and title (if applicable).

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* 17. Board member name and title (if applicable).

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* 18. Board member name and title (if applicable).

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* 19. Board member name and title (if applicable).

If your facility is for-profit, please indicate the name of the Managing Member/Owner and all Owner(s)/Controller(s) below and their corresponding percent of control/interest. 

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* 20. Managing Member/Owner.

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* 21. Managing Member/Owner's 24/7 phone number.

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* 22. Owner/Controller #2 name, 24/7 phone number, and percent of control/interest.

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* 23. Owner/Controller #3 name, 24/7 phone number, and percent of control/interest.

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* 24. Owner/Controller #4 name, 24/7 phone number, and percent of control/interest.

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* 25. Owner/Controller #5 name, 24/7 phone number and percent of control/interest.

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* 26. Owner/Controller #6 name, 24/7 phone number and percent of control/interest.

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* 27. Owner/Controller #7 name, 24/7 phone number and percent of control/interest.

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* 28. Owner/Controller #8 name, 24/7 phone number and percent of control/interest.

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* 29. Owner/Controller #9 name, 24/7 phone number and percent of control/interest.

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* 30. Owner/Controller #10 name, 24/7 phone number and percent of control/interest.

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* 31. If your nursing home is a not-for-profit facility, and you prefer to upload a list of current Board members, please do so here.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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