Facility Code Request Form

Facility Code Request Form

Please fill out the information below with your contact and facility/training program information to receive a Facility Code number for the Washington Project Firstline eLearning training series. Please only submit one form per facility/training program. Contact ProjectFirstline@doh.wa.gov with any questions.
This information is used to contact you regarding the code, training, and certificate. We use the facility code to verify the number of employees/students who have completed modules at your facility/training program. When 90% of your employees complete the training series your facility will become a Frontline Infection Prevention Champion.
For training programs, the facility code will help us identify the number of students who have completed the modules.
To show off this great accomplishment, you will receive a certificate and recognition on our website.
Full Name*

First NameLast Name
Job Title*
E-mail*
example@example.com
Facility/Training Program Name*
Facility/Training Program Phone Number- Please note this will be the number used to identify your facility in the system, so choose a number your staff/students will be familiar with.*
Facility/training program's main or general phone number w/area code (no symbols or spaces)
Facility Type*
Specify 'Other' Facility Type
Number of frontline healthcare workers currently employed*
If you are a training program, please add the estimated number of participants/students per cohort.
Delivery Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Facility Code Request Form

How To: Add/Edit the Facility Code on a User Profile