Job Site Approval Request Form

IAHCSMM 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 IAHCSMM 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:*

Invalid Input

Applicant Information

Applicant's First Name:*

Invalid Input

Applicant's Last Name:*

Invalid Input

Applicant's Street Address:*

Invalid Input

Applicant's City:*

Invalid Input

Applicant's State:*

Invalid Input

Applicant's Zip Code:*

Invalid Input

Applicant's Country (if outside the US):

Invalid Input

Applicant's Email:*

Invalid Input

Applicant's Phone:*

Please enter format as: 123-456-7890

Facility Information

Please provide the following information about your facility:

If Other, please specify:*

Invalid Input

Name of Facility:*

Invalid Input

Facility Street Address:*

Invalid Input

Facility City:*

Invalid Input

Facility State:*

Invalid Input

Facility Zip Code:*

Invalid Input

Facility Country (if outside the US):

Invalid Input

Facility Website:*

Invalid Input

Facility Contact (First and Last Name):*

Invalid Input

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

Invalid Input

Facility Contact's Phone:*

Please enter format as: 123-456-7890

How large is the facility?*

Small
Medium
Large

Invalid Input

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:*

Invalid Input

List the methods of Sterilization used:*

Invalid Input

List the mechanical cleaning equipment available:*

Invalid Input

List the types of sterile packaging materials available:*

Invalid Input

Hands-On Experience Checklist

Please address how the facility can provide the following experiences:

Cleaning and assembling patient care equipment:*

Invalid Input

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

Invalid Input

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

Invalid Input

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

Invalid Input

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

Invalid Input

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

Invalid Input

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

Invalid Input

Submit Form

Supporting Sterile Processing Professionals During COVID-19: See Our Resources

Site Approval Request

Applicant Information

Facility Information

Please List the Information Below

Hands-On Experience Checklist

Get Certified

Quick Links