Job Site Approval Request Form - Healthcare Sterile Processing Association (HSPA)

HSPA defines a traditional hands-on experience clinical site as a hospital or an ambulatory surgery center. Occasionally, applicants for certification request to obtain their hands-on experience at a non-traditional site such as a dental or optical facility, a clinic procedure area, or a veterinary practice.

All requests for the use of a non-traditional site must be approved by HSPA before time is scheduled at the site.

The process is as follows:

Before beginning the hands-on experience, the applicant should submit the form below.
The application will be reviewed to determine if the site has the capability of providing all the required hands-on experiences.
The applicant will be notified of the approval status (accept/reject).

Please note: Incomplete applications will not be processed.

Select the credential you wish to obtain:*

Please select one.

Today's Date:*

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Applicant Information

Applicant's First Name:*

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Applicant's Last Name:*

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Applicant's Street Address:*

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Applicant's City:*

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Applicant's State:*

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Applicant's Zip Code:*

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Applicant's Country (if outside the US):

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Applicant's Email:*

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Applicant's Phone:*

Please enter format as: 123-456-7890

Facility Information

Please provide the following information about your facility:

If Other, please specify:*

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Name of Facility:*

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Facility Street Address:*

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Facility City:*

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Facility State:*

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Facility Zip Code:*

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Facility Country (if outside the US):

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Facility Website:*

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Facility Contact (First and Last Name):*

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Facility Contact's Email
(*Must be a business email address):*

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Facility Contact's Phone:*

Please enter format as: 123-456-7890

How large is the facility?*

Small
Medium
Large

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Average number of cases per day:*

Please enter a number.

Number of procedure rooms:*

Please enter a number.

Number of sterilizers:*

Please enter a number.

Please List the Information Below

List the types of surgical procedures performed at this facility:*

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List the methods of Sterilization used:*

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List the mechanical cleaning equipment available:*

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List the types of sterile packaging materials available:*

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Hands-On Experience Checklist

Please address how the facility can provide the following experiences:

Cleaning and assembling patient care equipment:*

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General cleaning of instruments, utensils, and specialty items and the operation of mechanical washers:*

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Packaging using pouches, flat wraps, and rigid containers:*

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Instrument and procedure tray preparation (assembly/layout, inspection, and identification):*

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Sterilization (high temperature and low temperature sterilization processes, use of sterilization quality assurance systems, record keeping, and sterility maintenance):*

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Clean and sterile storage (rotating supplies, inventorying and restocking carts/shelves, outdates, and cleaning storage shelves):*

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Quality assurance processes, blood borne pathogen protocols, soiled equipment pick-up, standards, regulations, policies and procedures:*

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Submit Form