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Honor Roll Checklist and Submission Process

Honor Roll Checklist: 

Phase I:

Letter to Georgia Antibiotic Stewardship Subcommittee.  Letter to include:

 

Signature by Senior Executive and Board Member

 

Statement of commitment of facility to engage in antibiotic stewardship

 

An education event to be conducted within one year (include title/content of event, target audience, and date to be held)

Phase II:

 Letter with Phase 1 content (above)  with the following additions:

 

Statement of stewardship activity and how the activity was selected (e.g., risk assessment, committee meeting, or Georgia Antibiotic Stewardship Assessment  tool from October 2013 Pharmacist Training)

 

Statement of how the intervention is measured

Attach documentation of your selection of the intervention (i.e., attach your risk assessment, meeting minutes that document your selection, or the Georgia Antibiotic Stewardship Assessment  tool from October 2013 Pharmacist Training).

Attach at least three months of data representing your stewardship intervention.

Submission Process:

  1. Submit an email to jenegley@dhr.state.ga.us.  State that you wish to apply for the Antibiotic Stewardship Honor Roll in your email, and whether you wish to apply for Phase I or Phase II.
  2. Include the following attachments to your email:
  • A scanned* copy of your signed letter (Phase I and Phase II)
  • Documentation of your selection of a stewardship activity (Phase II)
  • A minimum three-month data summary representing your stewardship intervention (Phase II).

*If your facility does not have a scanner, state in your email that you will fax the application materials to 404-657-7517.