Preliminary Application for an AAP Neonatal Verification Survey

Preliminary Application for an AAP Neonatal Verification Survey
Thank you for your interest in the AAP NICU Verification Program (NVP). As the first step in obtaining verification through the American Academy of Pediatrics, please complete the following application as thoroughly as possible. A separate application should be submitted for each hospital/site.

Questions about this application should be directed to the NVP Team at NICUVerify@aap.org.
Facility Name
Facility Address

Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Contact Information

First and Last Name

Institutional Role/Title

PhoneState / Province

Email
Neonatal Medical Director

First and Last Name

Credentials

PhoneState / Province

Email
Neonatal Nursing Leader

First and Last Name

Credentials

PhoneState / Province

Email
Neonatal Senior Administrator

First and Last Name

Credentials

PhoneState / Province

Email
Neonatal Level of Care
Does the state in which your facility is located have any of the following related to neonatal care? (Please select all that apply.)
If yes, please briefly describe the program(s) and indicate the organization or agency responsible for oversight of the verification and designation process:
Please select the level of care for which a neonatal verification survey is requested:
Is your facility and/or providers affiliated with Mednax/Pediatrix?
By typing my full name in the box, I attest to the validity of this application and confirm our facility's readiness to proceed with the verification process.
Should be Empty:

Preliminary Application for an AAP Neonatal Verification Survey

Neonatal Level of Care